Inspection on 13/12/05 for Mulroy`s Seaview

This inspection was carried out on 13th December 2005.

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

Mulroy`s Seaview 02/10/06

Mulroy`s Seaview 15/08/05

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Mulroy`s Seaview 19-22 Newcommen Terrace Redcar TS10 1AU Lead Inspector Jackie Herring Unannounced Inspection 13th December 2005 09:30 X10029.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 Mulroy`s Seaview DS0000055582.V278627.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 and Care Homes for Adults 18 – 65*. 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. Mulroy`s Seaview DS0000055582.V278627.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mulroy`s Seaview Address 19-22 Newcommen Terrace Redcar TS10 1AU 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) 01642 493759 01642 493759 Mr David McArthur Mrs Kay McArthur Care Home 21 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (13) Mulroy`s Seaview DS0000055582.V278627.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th August 2005 Brief Description of the Service: Mulroys Seaview is a 21 bedded care home providing nursing care to older people and younger adults with mental health problems. The home is a converted property on the seafront at Redcar and close to the town centre, with a wide town centre facilities. All of the rooms are single bedrooms with ensuite facilities, although one room is substantial in size and is being used as a double with the approval of CSCI. The home provides accommodation across three floors, with the younger adults occupying the second floor. Mulroy`s Seaview DS0000055582.V278627.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection and was completed in one inspection day, eleven inspection hours in total by two inspectors. A group discussion took place with three residents and there was individual discussion with a further two. Three staff were interviewed and there was discussion with the manager and deputy manager. Both direct and indirect observation took place and a range of records were examined including residents files and maintenance records. This was again a very positive inspection and both of the inspectors felt warmly welcomed into the home by the deputy manager who conducted himself very professional and with sound knowledge. There was much discussion throughout the inspection, which was very constructive and any areas identified for further development were positively received by the manager and deputy. What the service does well: What has improved since the last inspection? A dedicated car/people carrier has been purchased which has increased opportunities for trips and outings. Staff supervision systems have now been introduced and the smoking area in the courtyard garden has been improved offering more protection to residents in the winter and periods of bad weather. Mulroy`s Seaview DS0000055582.V278627.R01.S.doc Version 5.1 Page 6 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. Mulroy`s Seaview DS0000055582.V278627.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Mulroy`s Seaview DS0000055582.V278627.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were examined during this inspection. EVIDENCE: Mulroy`s Seaview DS0000055582.V278627.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are 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, 9 Whilst individual residents records are well written and demonstrate clear details plans of care, there is the need to show evidence of resident’s involvement and consultation with their individual plans. The medication procedures are in place, however some further development is required to ensure further robustness. Mulroy`s Seaview DS0000055582.V278627.R01.S.doc Version 5.1 Page 10 EVIDENCE: Two sets of resident’s records were looked at during this inspection specifically to identify if residents has been involved with their individual assessment of need and plans of care as this was an outstanding requirement from the previous inspection. Whilst the records continue to be very well written and contain very detailed information about individual residents needs and how these needs are to be met, there continues to be only a small amount of evidence detailing resident’s involvement. This was discussed in detail with the manager who agreed that there is still work to do in this area and a written consultation process had been developed, which will be introduced in the near future. Residents were very clear that their individual needs were being met in the home, one resident said, “I feel that I have improved in the time I have been living here”. Another resident said, “I am getting better, I am able to discuss my mental health and there is a good understanding and awareness of mental illness within the home”. The medication procedures were examined along with the storage arrangements and in the main found to be reasonable robust. It was however identified that there needed to be a system for recording medication that is disposed. It was also identified that there is the need to ensure the medication trolley is secure when not in use and not in the medication cupboard. It was also identified that there had been some medication errors that had not been reported to CSCI and it was unclear what action had been taken. Mulroy`s Seaview DS0000055582.V278627.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were examined during this inspection. EVIDENCE: Mulroy`s Seaview DS0000055582.V278627.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The residents are generally protected from abuse however further staff training is required on this topic. EVIDENCE: Procedures are in place in respect of Protection of Vulnerable Adults and staff were clear about the reporting of any incidents of abuse. Actual training in regard to this topic is currently in part delivered through the induction and foundation training for care workers, however further training is required for all of the staff employed at the home. Mulroy`s Seaview DS0000055582.V278627.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) 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 The internal environment at Mulroy’s Seaview is clean and well maintained and conducive for the residents needs. Redecoration of the external aspects of the home needs to be completed. EVIDENCE: The environment at Mulroy Seaview continues to be very pleasing, homely and very clean. Mulroy`s Seaview DS0000055582.V278627.R01.S.doc Version 5.1 Page 14 Residents continue to speak very proudly of their home and said, “This is home from home, the environment is so much better”, “I have a lovely room with my own ensuite”. “When I visited I liked it immediately, it’s homely and the ideal place for some people and the rooms are kept immaculately clean”. An outstanding recommendation from the last inspection was in regard to the external smoking area and the need to increase the level of protection for the residents in the winter months or during periods of bad weather. This area was now more protected although there is still quite a wide opening, this will continue to be monitored. Work had commenced on the external paintwork at the front of the house; the rear of the house was also in need of redecoration. Mulroy`s Seaview DS0000055582.V278627.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Training of staff should continue, ensuring that staff are competent to do their jobs and all training should be recorded and able to be evidenced. EVIDENCE: Training was discussed with the manager who confirmed of the twelve care workers four have completed their NVQ Level 2 in care, a further three are underway with it and three more care workers will be commencing in February 2006. It was also noted that additional training had taken place such as dealing with aggression/ Conflict Resolution, which was described as a very good and informative course. Client specific training was discussed and currently this is delivered on a more informal basis, however it is planned that this will be built upon over time. There was also discussion with the manager about the recording of training as there was no clear system in place to establish who had received what training and who still needed to undertake. Mulroy`s Seaview DS0000055582.V278627.R01.S.doc Version 5.1 Page 16 Staff were interviewed confirmed that they had received induction and foundation training as well as mandatory training such as manual handling, fire safety, first aid and food hygiene. Mulroy`s Seaview DS0000055582.V278627.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 36, 38 Seeking of residents’ views and quality assurance is in need of further development as no formal systems are in place. The management of resident personal allowance is good and records are place to safeguard. The system for supervision of staff is now in place and being implemented. Mulroy`s Seaview DS0000055582.V278627.R01.S.doc Version 5.1 Page 18 The frequency for the routine fire check, fire drills and water temperatures needs to be increased to promote and protect the health and safety of residents. EVIDENCE: Quality assurance was discussed with the manager who confirmed that this was an area that continued to be in need of development. Informal systems such as regular discussion with residents, effectiveness of social activities were described however it was confirmed that no formal systems are currently in place. The system for the management of residents personal allowances was also examined and found to be a good system with detailed supporting records. Staff supervision was discussed and it was confirmed through staff interviews that this is taking place Equipment service records were not available within the home on the day of the inspection, copies of these were however forwarded to CSCI following the inspection and included amongst others up to date certification of the passenger lift, chair lift, fire equipment and also the certificate of employers’ liability insurance. Fire checks were not being completed on a weekly basis and the manager agreed to take immediate action to address this. The system for recording fire tests, fire drills and evacuation was not adequate and it was difficult to determine when drills had occurred and who had attended. From the information made available fire checks were not being completed weekly and an insufficient number of fire drills had taken place. The manager agreed to take immediate action to address this. Water temperatures for baths was being checked and recorded, however temperatures of showers and wash hand basins were not, again the manager was taking steps to address these matters straight away. Mulroy`s Seaview DS0000055582.V278627.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 CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 ENVIRONMENT Standard No Score 19 3 20 2 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 X 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 X 32 X 33 2 34 X 35 X 36 3 37 X 38 2 Mulroy`s Seaview DS0000055582.V278627.R01.S.doc Version 5.1 Page 20 YES 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 13 Requirement Where possible, residents must be consulted about their assessments and care plans and there must be evidence contained within their individual files. (This is outstanding from 01/11/05) Medication systems and security must be reviewed and updated and a number of staff must receive further updating on administration of medication. All staff must received training in respect of abuse and No Secrets. (This is outstanding from 01/12/05) A quality assurance system must be developed and implemented and must include residents views. Routine health and safety checks - weekly fire checks, fire drills and water temperatures (showers/wash hand basins) must take place and there must be effective recording systems in place. Timescale for action 01/05/06 2. OP9 13 13/12/05 3. OP18 13 01/05/05 4. OP33 24 01/06/06 5. OP38 23/37 13/12/05 Mulroy`s Seaview DS0000055582.V278627.R01.S.doc Version 5.1 Page 21 CSCI must be notified of incidents and accidents as detailed within Regulation 37. 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. Refer to Standard OP20 OP30 Good Practice Recommendations Work should continue on the redecoration of the outside of the home. 50 of staff should be trained to NVQ Level 2. Training records should be developed to show what training has taken place, who has attended and how up to date it is. Mulroy`s Seaview DS0000055582.V278627.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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. Mulroy`s Seaview DS0000055582.V278627.R01.S.doc Version 5.1 Page 23 - 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. 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