Inspection on 15/03/06 for Mulgrave House

This inspection was carried out on 15th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 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 15/01/09

Mulgrave House 21/11/06

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mulgrave House 9-11 Springfield Street Rothwell Leeds Yorkshire LS26 0BP Lead Inspector Sue Dunn Unannounced Inspection 15 March 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 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. Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mulgrave House Address 9-11 Springfield Street Rothwell Leeds Yorkshire LS26 0BP 01927 573747 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) Camelia Care Limited Mr Kevin Brown, Mrs Julie Ann Brown Mrs Susan Nyakwangwa Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33), Terminally ill (3) of places Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th July 2005 Brief Description of the Service: Mulgrave House provides personal and nursing care for 33 older people. It was established in 1987 and has recently been re registered under new ownership. 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. There are three areas for communal dining/sitting. The upper floor is accessible by passenger lift. 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. Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on an unannounced inspection carried out by one inspector between 10.am and 3pm. Comment cards and pre paid envelopes were left in the home to give people the opportunity to express their views about the home in a confidential way. The purpose of the inspection was to ensure the home was operating and being managed to a satisfactory standard and in the best interests of the people who live there. The inspector toured the building, spoke to several residents and two visitors, sampled the food, inspected some documentation, and spoke with three members of staff. The manager and proprietor assisted with the inspection. There were two requirements and four recommendations made during this inspection. This is a well run home which operates and is managed for the benefit of the residents. What the service does well: What has improved since the last inspection? Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 Page 6 The new proprietors have plans for an intermediate care service for the benefit of people in the local community who have been in hospital and need care to phase them back into their own homes. The proprietors have made changes to the catering arrangements and now provide more choices at every mealtime. The laundry equipment has been replaced and there is an ongoing programme of replacement beds for the comfort and safety of residents and staff. The manager has completed training in the protection of vulnerable adults. The proprietors have made positive changes in response to the result of surveys of residents’ views about the service. 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. Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 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 Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 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): 1,2, The Statement of Purpose and contracts must be reviewed to reflect the change of ownership. EVIDENCE: The proprietor is in the process of reviewing the Statement of Purpose to reflect the changes brought about since the home changed ownership. The new document is to be in larger print and will include pictures of the home and the management team. The existing document continues to be used until this is ready. Residents and their families all received a letter informing them about the new owners. The present owners have not revised the contracts outlining the terms and conditions of occupancy between themselves and each service user. This has been an oversight, which the proprietor agreed to redress. The proprietor and manager met on the day of the inspection to discuss the preparation for an application for a contract to provide intermediate care. It is proposed that a bungalow in the grounds, which is to be adapted, will provide a suitable extension for this purpose. Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 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): 7,8,10,11 Residents were satisfied that their health and social care needs were met and care plans provided clear instructions for staff to follow. Residents were treated with respect and their privacy was upheld. Staff had a good understanding of each person’s preferences EVIDENCE: Two care files were inspected, one for a person who had been recently admitted from another home. It was apparent that staff had obtained background information to allow them to make provision for emotional and recreational needs as well as physical care needs. Risk assessments had been done but a care plan had not yet been written. The other care file was detailed enough to show the care being provided. It was encouraging to see that care staff, in their role as key workers, contributed to the reviewing of care plans. During the tour of the building it was seen that staff had made provision for tastes, preferences and individuality of service users. The manager had been on leave but was aware of the new service user’s preferences. Peoples’ wishes regarding care at the end of life are discussed at the time of admission. The home uses a ‘care pathway’ approach for people who are Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 Page 10 terminally ill, working closely with the Rapid Response team and McMillan nurses to ensure people are kept pain free. Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 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): 13,15 Residents are encouraged to participate in social and leisure activities, to maintain links with their friends and family and to exercise choice and control over their lives. A good, varied and nutritious diet takes into account individual choices and dietary needs. EVIDENCE: The people spoken with felt well cared for. Visitors who were coming in and out of the home during the course of the day were relaxed and known to the staff. One person had concerns that changes in staff had an effect on the continuity of care, as new staff were adapting to routines, but apart from this said ‘there is nothing I can grumble about’. Staff accommodated peoples’ routines prior to coming in to the home and several people were seen to have their own bottles of whiskey or beer in their room. A vicar visits the home every Thursday to give communion and some people have support from their own churches. Many service users have close links with the area and each other. Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 Page 12 The local newspaper has taken an interest in the home and reports any special events and activities. An experienced cook with city and guilds catering qualifications has been employed and the new owners have introduced more choice at mealtimes. A review and re negotiation of the kitchen staffs’ rotas ensures staff are available at the end of the day to provide a hot and cold choice at teatime. The three course lunch on the day of the inspection was soup, turkey or corned beef hash with potatoes, two vegetables, Yorkshire pudding and gravy followed by Bakewell tart and custard, cheese and biscuits, fresh fruit or yogurt. Soft drinks were served with the meal followed by tea or coffee. The meat was tender and the food hot and tasty. The food served to those people who needed a soft diet was well presented in its individual components. Tables were laid with cloths and cruets but there was an absence of napkins for people sitting at the table. One person sitting at a small table was seen to have difficulties, as the table could not be drawn close enough for her to eat with ease. ‘Sixty to seventy’ relatives and friends joined service users for a Christmas meal in the home a couple of weeks before Christmas. Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 Page 13 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): 16,17,18 Residents and their relatives have their views listened to, taken seriously and action is taken to resolve issues. The manager and staff are aware of adult protection issues. The proprietor should seek advice from the adult protection team about the action to take to ensure all residents receive sufficient personal allowance from their families to meet their needs. Residents are supported to exercise their right to vote. EVIDENCE: The general feeling was that if people did complain there was no fear of repercussions. Staff listened and quickly tried to put things right. The proprietors visit the home on a regular basis during the week and make a point of speaking to each person individually. The manager did adult protection training in November 2005 and this is incorporated into the 12-week staff induction programme. There were concerns that some families were not providing service users with sufficient personal allowance to provide for their needs. In such cases the home paid for toiletries, suitable clothing, hair and foot care. The withholding of money can be a form of financial abuse. It is suggested the home seek advice from the adult protection team. It was apparent that some people in the home have strong political views and like to express them. They confirmed that transport is provided if they wish to register they votes at the polling station. The local Member of Parliament visited the home recently and the proprietor hopes to generate some interest from local councillors Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 The home offers a clean, safe, environment for the residents and provides appropriate bathing, toilet facilities and specialist equipment. Systems are in place for the upkeep and maintenance of the building and equipment. Some work is needed to maintain satisfactory levels of odour control in all parts of the home. The standard of care for personal clothing is high. EVIDENCE: The maintenance man was on holiday on the week the inspection took place. Part of his responsibility is to check the suitability and safety of bed rails. The inspector was told that beds are being replaced each month for the comfort of residents and the safety of staff. The equipment in the laundry had been replaced since the new owners took over the home. Staff were very pleased with the new machines. It was evident from seeing the way that service users were dressed that that the home maintains a high standard of care for personal clothing. Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 Page 15 The home has a high proportion of double rooms which the proprietors have plans to reduce. The bedrooms, which varied in shape and size, contained personal items, which created an atmosphere of ownership. Some people had a key to their own room or had access to their own key. Each room had a lockable piece of furniture for the safety of personal possessions. Some had en suite facilities. There is a walk in shower which many people were said to prefer and bathrooms were warm and had equipment to make bathing comfortable for staff and residents All parts of the home were clean and well furnished but there was an odour noted around those parts of the internal corridors which do not have any natural ventilation. Staff thought that the automatic air purifying units in the corridors might need changing. A range of communal rooms gave people choices of quiet or more active areas of the home in which to sit. The gardens were neatly tended, providing a pleasant outlook for service users. Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 30 Residents are supported and protected by robust recruitment procedures. A proactive approach to recruitment maintains staffing numbers and skills to ensure that residents’ needs are met. The home has a planned training programme which includes the NVQ award. EVIDENCE: The staff were pleasant and relaxed on the inspector’s arrival. Nurses and care staff appeared to work well together and had a good knowledge of the service users. The relationship between staff and service users was caring and friendly with service users commenting if they felt staff looked unwell. The proprietor and manager have reduced the use of agency staff in the home by taking a firm stance on the hours staff are required to work. This has been compensated for by enhanced rates of pay and an increase in payments for weekend work. The proprietor has had previous experience of personnel management and has set clear expectations and guidance to reduce sickness levels. The management have adopted a proactive approach to staff recruitment and have recruited three new staff in anticipation of vacancies in June due to maternity leave. The proprietor has liaised with the Home Office and documentation for overseas staff is carefully vetted to ensure they have authorisation to work. This was not checked during the inspection. Seven of the twenty-two staff had the NVQ award and 5 were working towards it. The training plan for 2006 showed that more staff are to register for NVQ. Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 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, 32, 33, 35, 36, 38 The proprietors and manager have the skills, knowledge and experience to provide effective leadership. Staff are well motivated, residents are consulted and their interests are safeguarded at all times. EVIDENCE: The manager is well qualified to manage the home having completed a degree in Management in addition to her nursing qualifications. She is supported by the proprietors of the home who are from accountancy and management backgrounds. Annual surveys are undertaken to get peoples views about the home with research carried out concerning particular areas of the service. Changes to the menus and catering arrangements resulted from such an exercise. The manager has had little success with formal meetings as service users and relatives feel that if they have anything to say they can do so at any time. The home has good support from relatives past and present. The proprietors visit Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 Page 18 the home several times during the week and speak to service users on an individual basis. Most residents’ finances are handled by their relatives, some of whom leave money with the home to cover the cost of such things as hairdressing, personal toiletries and chiropody. The home keeps records of money spent on behalf of people and will invoice the relatives if there is no money left in the home. It is recommended that each person have his or her own purse or wallet for the storage of any money held by the home. The manager ensures people have money when they go out. The maintenance person keeps records of all the health and safety checks carried out and these are monitored by the proprietor on a regular basis. Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 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 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 2 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 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 3 18 3 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 x 3 3 x 3 Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5 Requirement All residents must have a contract stating the terms and conditions of their occupancy agreement with the new owners Action must be taken to ensure all parts of the home are free from unpleasant odours Timescale for action 31/05/06 2 OP26 16 31/05/06 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 4 Refer to Standard OP1 OP15 OP18 OP35 Good Practice Recommendations A copy of the revised Statement of Purpose should be sent to the CSCI Residents should be provided with napkins and positioned close enough to the table for ease of eating. The proprietors should seek advice from the adult protection team on behalf of those residents who are not receiving sufficient personal allowance for their needs. It is recommended that each resident have a purse or wallet for any money held on their behalf. Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mulgrave House DS0000064994.V255823.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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