Inspection on 21/11/06 for Mulgrave House

This inspection was carried out on 21st November 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 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 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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mulgrave House 9-11 Springfield Street Rothwell Leeds Yorkshire LS26 0BP Lead Inspector Valerie Francis Unannounced Inspection 21st November 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.V314279.R03.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. Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mulgrave House Address 9-11 Springfield Street Rothwell Leeds Yorkshire LS26 0BP 0113 2821 937 0113 282 1654 brownacs@aol.com 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 36 Category(ies) of Old age, not falling within any other category registration, with number (33), Terminally ill (3) of places Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th March 2006 Brief Description of the Service: 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. 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 £383 to £566 per week. Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group, for example, Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk This report brings together evidence gathered at this first Key unannounced Inspection visit to Mulgrave House on the 21st November 2006 by one inspector over a period of 7 hours. This inspection was carried out to assess the home against a pre-determined selection of the National Minimum Standards for Care Homes. The purpose of the visit was to make sure the home was being managed for the benefit and well being of the residents and to see what progress had been made meeting requirements in place from the last inspection. Information to support the findings in this report was obtained by looking at the information supplied in the pre inspection questionnaire (PIQ). Examples of information gained from this document include details of policies and procedures in place and when they were last reviewed, when maintenance and safety checks were carried out and by who, menus used, staff details and training provided. Records in the home were looked at such as care plans, staff files, and complaints and accidents records. Residents, their relatives and visitors were spoken to as well as members of staff and the management team. CSCI comment cards and post-paid envelopes were sent to the home to be given to residents and their relatives before the visit was made. At the time of writing this report fifteen resident survey responses had been received. The day after the inspection a copy of the home’s improvement plan was sent to the CSCI area office. Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Residents must have a care plan that clearly identifies all their care needs. Residents care plans must have information to show that they and their relatives have been involved in the care planning process. The matter of the storage of wheelchairs in the bathroom identified must be resolved. All residents must have a contract stating the terms and conditions of their occupancy agreement with the new owners. The registered manager and provider must make sure that they follow their recruitment and selection procedures at all times. All new staff must have a satisfactory Criminal Records Bureau check before taking up employment. Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 7 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.V314279.R03.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 Mulgrave House DS0000064994.V314279.R03.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Residents’ needs are properly assessed before they move into the home. These needs are met by well informed and knowledgeable staff. EVIDENCE: Prospective residents and other interested parties have access to the newly developed Statement of Purpose and Service User Guide, which is also given to people living in the home. The document provides people who wish to access the service with information on what services are available at the home. Each resident is given a terms and conditions agreement from the new registered provider. Pre-admission assessment information for each of the residents was on file and the information was accurately used to form the basis of a care plan. The manager said she always tries to get a copy of the multi agency assessments but invariably found them to be out of date. Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 10 The staff spoken with had a good knowledge of the residents care needs and their personal preferences. Residents said that the staff are very caring and the relatives also confirmed this. The home does not provide intermediate care. Mulgrave House DS0000064994.V314279.R03.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Resident’s needs are met, they are treated with dignity and their privacy is maintained. Staff are aware of the residents’ needs but the care plans need to be more detailed and individual in order to fully inform staff. EVIDENCE: Three residents care plans were looked at. The care plans are written using information from the pre admission assessment and other assessments that are carried out when the resident comes to live in the home. More work needs to be done to make plans more person centred. Resident’s relatives had provided staff with information about the person and their life history to enable staff to get to know more about the individual’s life. Although care plans were in place for residents they did not always identify all their care needs, such as one person with an infection, but no plan of action to be taken to manage this. One person who clearly had to be helped to move by staff had no moving and handling plan. There was no evidence on any of the care files seen showing that residents or their relatives been involved in the care planning process, plans had not always been dated and signed. Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 12 Most care plans were evaluated monthly. Some had been reviewed in full with input from the resident, their relatives and other involved people such as social workers and district nurses. Staff said plans were in place to make sure that all care plans were reviewed. Although risk assessments are carried out, the format does not allow anywhere for staff to record any plan of action that needs to be taken. A resident at risk from falls did not have a plan in place showing how they should be moved safely after a fall. The home works closely with health care professionals and other agencies to make sure the needs of people living in the home are met. Residents dietary needs are met and nutritional assessments are carried out for residents. Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 13 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): 12,13,14 & 15. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Residents are encouraged to make their own decisions about their lifestyle. Family, friends and visitors are welcomed at the home. Social and leisure activities are offered that most people are happy with. EVIDENCE: In the conversations with residents it became clear that they enjoy a large degree of freedom and choice about their daily routines like getting up and going to bed times. Some have telephones to keep in more regular contact with family and friends. They choose whether to join in activities, how to spend their time during the day, with some preferring to spend time in their rooms reading, listening to the radio and watching TV. There is a range of activities organised by the home’s activity manager. During discussion with the registered provider it was said that there are plans in place for more activities that will focus on specific individuals. The residents spoken with said that they have in-house activities that include entertainers, and there are trips out and visits from local churches. Visiting relatives said that they felt very comfortable and welcome at the home saying that staff are approachable, friendly, welcoming and easy to talk to. Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 14 Residents said that they food was good and there is always a choice of food available if they did not like what was being prepared. Assistance was seen to residents in a relaxed and friendly manner. Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 15 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 &18. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Residents and their relatives have their views listened to, taken seriously and action is taken to resolve issues. Residents feel safe living in the home. The manager and staff are aware of adult protection issues. EVIDENCE: The complaints procedure is in the service user guide that is given to all residents. It is also posted on notice boards in the entrance to the building. All of the residents spoken with said that they felt comfortable in raising concerns with staff and that when they did, staff acted quickly to put things right. The relatives were aware of the complaints procedure, confident in approaching staff, manager, or the owners. They said that anything raised would be sorted out. The manager did adult protection training in November 2005 and this is incorporated into the 12-week staff induction programme which has provided most staff at the time of the inspection with knowledge of what to do if an incident of abused occurred. Although the home has an adult protection procedure, they did not have a copy of the multi-agency procedure. Advice was given that additional information should be included in the home’s whistle blowing policy procedure, Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 16 so that staff who whistle blow feel that they would be protected all through the process. All new staff have POVA first check before taking up employment at the home. Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 17 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 & 26 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The home offers a comfortable environment for the residents. People are able to personalise their bedrooms. Systems are in place for the upkeep and maintenance of the building and equipment. Storage areas needed to be utilised so that communal areas used by residents are kept free of wheelchairs and other equipment. The standard of care for personal clothing is high. EVIDENCE: Most of the people came from the surrounding areas of Rothwell which their relatives and friends find is accessible. All the communal areas, laundry and some bedrooms were seen. No health and safety hazards were noted and staff were seen doing their work properly Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 18 dressed and equipped, and their practices make sure the home is clean, hygienic and free from unpleasant smells. Since the last inspection three new bedrooms have been registered with the Commission increasing the number of residents to the home to 36 all rooms have en suite facilities. There were wheelchairs and other equipments stored in one of the communal bathrooms designated to these three rooms. Advice was given to the manager that this room need to be kept free so that people using this area is free of health and safety hazards. Carpets in the halls on the ground floor were showing signs of wear and tear. The registered provider said these are part of the home’s planned refurbishment and replacement programme. The bedrooms seen were comfortable, well furnished and personalised with resident’s own belongings. There is a wide range of standard and specialist aids and equipment that staff are trained to use. Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 19 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): 27,28.29 & 30. The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Residents are not always protected by the way the recruitment process is carried out. 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 awards. 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 residents. The relationship between staff and service users was caring and friendly, and residents commented that they felt the staff looked after them well. The registered person has plans in place to increase staffing levels to meet the nursing needs of people who are and will be nursing care. The inspector advised that when the home has all nursing care residents then the staffing level must be constantly be reviewed to make sure that residents have access to enough staff to meet their changing needs. The management have adopted a proactive approach to staff recruitment Although the home have a robust recruitment policy and procedure, information in the two staff recruitment files seen did not have information that references were requested or an interview had taken place, there were no copies of staff terms and condition on their files. Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 20 The registered provider said that these staff were family members of the manager and no written references were given. The copies of the contracts were held in files at the registered proprietors’ home. However the proprietor has liaised with the Home Office and documentation for overseas staff is carefully vetted to ensure they have authorisation to work. These documents were seen. Although applications for CRB checks had been made there was no evidence to indicate that the registered persons had received a satisfactory CRB. The manager said POVA first checks are carried out and an induction course and people are supervised whilst CRB checks are received. Ten of the eighteen care staff have an NVQ qualification and two nurses are undertaking the work based assessor award so the all staff have the opportunity to undertake an NVQ training. Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 21 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): 31,33,35 &38. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home is being well managed and run in the best interests of residents. EVIDENCE: The manager is well qualified to manage the home having completed a degree in Management in addition to her nursing qualifications. The proprietors of the home who are from accountancy and management backgrounds support her. 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. Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 22 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 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. Purses and wallet are used for the storage of any money held by the home. Records are kept of all health and safety checks carried out by the maintenance man, which are monitored by the proprietor on a regular basis. The manager must ensure that the maintenance man also has moving and handling training which he needs for carrying and lifting of loads. Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 23 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? 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 OP7 Regulation 15 Residents must have a care plan that clearly identifies all their care needs. Residents care plans must have information to show that they and their relatives had been involved in the care planning process. The matter of the storage of wheelchairs in the bathroom identified must be resolved. The registered manager and provider must make sure that they follow their recruitment and selection procedures at all times. All new staff must have a satisfactory CRB before taking up employment. Requirement Timescale for action 31/12/06 2. 3. OP38 OP29 13 18 31/12/06 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 25 No. Refer to Standard Good Practice Recommendations Mulgrave House DS0000064994.V314279.R03.S.doc Version 5.2 Page 26 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.V314279.R03.S.doc Version 5.2 Page 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. 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