Inspection on 20/06/05 for Nelson Mandela House

This inspection was carried out on 20th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Nelson Mandela House 07/08/06

Nelson Mandela House 04/10/05

Nelson Mandela House 01/12/04

Nelson Mandela House 03/06/04

Nelson Mandela House 30/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Nelson Mandela House Whitburn Close Pendeford Wolverhampton WV9 5NJ Lead Inspector Ian Harris Announced 20 June 2005 08.00 th 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 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. Nelson Mandela House E56 000035973 Nelson Mandela House v229802 AI 200605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Nelson Mandela House Address Whitburn Close, Pendeford, Wolverhampton, WV9 5NJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01902 553462 01902 553468 Wolverhampton City Council Sylvia Campbell Older People 37 Category(ies) of Dementia (8) registration, with number Mental Disorder (8) of places Old Age (29) Nelson Mandela House E56 000035973 Nelson Mandela House v229802 AI 200605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) 50 years and above. 2) Kinver unit 8 residents caetgory DE, MD only, with no number division between categories. Date of last inspection 01.12.04 Brief Description of the Service: Nelson Mandela House opened in 1986; it is one of four residential homes for the elderly managed directly by Wolverhampton City Council Social Services. The home is located in the centre of a large estate in close proximity to a supermarket, other shops, a library and a public house. Accommodation is available for up to 37 people in single bedrooms all of which are on the ground floor. There is a day centre, which is not inspected. The accommodation is divided into four separate units Chilington, Milford Wenlock and Kinver. Each unit has a dining /sitting room with a small kitchenette facility in each unit. The building houses a central kitchen and associated office space. Kinver unit is specifically used to provide respite care for a maximum of eight service people with mental health needs, usually dementia. There are car-parking facilities to the front of the property and two enclosed garden areas. Nelson Mandela House E56 000035973 Nelson Mandela House v229802 AI 200605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place over 4 hours. The main purpose of the inspection was to check the progress made by the home regarding the recommendations and requirements made in the last inspection report. The fullest co-operation was given to the inspection officer by the Care Manager staff and residents. During the inspection a tour of the premises took place and staff and care records were inspected. Also staff rotas and general records regarding the maintenance of the home were checked. 9 of the 31 Care staff were on duty, and 10 of the 36 residents were spoken to. 25 residents comments cards and 8 relatives comments card were received all with positive comments. On the day of inspection the atmosphere within the home was found to be warm, friendly and comfortable and safe with contented residents. What the service does well: Nelson Mandela continues to provide a high standard of care. The Care Manager and staff are to be commended on their efforts to encourage the residents to maintain their independence through social activities both within and outside the home. The provision of a Mini bus is a great asset to the home. The residents key-worker system is working well and ensures, that residents’ wishes are being met. Observations during the inspection saw very attentive staff providing for the individual needs of the residents. A number of residents confirmed that the Staff are very supportive as do the comment cards. The home has a good staff- training programme, which all staff are involved in, this ensures that they are improving their knowledge and skills. Nelson Mandela House E56 000035973 Nelson Mandela House v229802 AI 200605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Nelson Mandela House E56 000035973 Nelson Mandela House v229802 AI 200605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Nelson Mandela House E56 000035973 Nelson Mandela House v229802 AI 200605 Stage 4.doc Version 1.30 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 standard(s) 3 and 6 Appropriate assessments of need are in place and are carried out. The home does not provide intermediate care. EVIDENCE: There is evidence on the files that all the residents who are funded by the Local Authority undergo a full multi-disciplinary assessment prior to admission. The residents who are self funding are assessed by the Care Manager, using the homes assessment forms The home does not provide intermediate care. Nelson Mandela House E56 000035973 Nelson Mandela House v229802 AI 200605 Stage 4.doc Version 1.30 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 standard(s) 7, 8, and 9 Each resident has a comprehensive individual care plan that is reviewed on a monthly basis. The home has good contact with local G.P. s. local hospitals and paramedical services, which ensures that resident’s health needs are met. The systems for the administration and recording of medication are good with clear and comprehensive arrangements being in place to ensure resident’s medication needs are met. EVIDENCE: The home provides a comprehensive Care Plan for each individual resident based on the initial assessment. The Care Plans are drawn up by the Care Staff in consultation with the resident and their family. There was evidence on the files to show the care Plans are being carried out and reviewed on a monthly basis. The home is well supported by local G. P. s. and all of the paramedical services. Wherever possible, the residents are encouraged to retain their own G. P s, Opticians, and Dentists. It was noted that if the resident has moved out of their area the Care Manager ensures that these services are provided, by Nelson Mandela House E56 000035973 Nelson Mandela House v229802 AI 200605 Stage 4.doc Version 1.30 Page 10 local practitioners. The records indicate that resident’s medical needs are being met. Medication is administered, by means of a monitored dosage system. The system appears to be working very well. The home receives good support from the local pharmacist who does a three monthly audit of the homes medication. All care Senior Staff have been trained to use the system before they are allowed to administer medication. The home has very good draft policies and procedures, which are used as an integral part of the care staff induction programme. Nelson Mandela House E56 000035973 Nelson Mandela House v229802 AI 200605 Stage 4.doc Version 1.30 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 standard(s) 12 and 15 The home provides a stimulating experience for the residents where they are encouraged to maintain their independence as much as possible The home provides a range of social activities within and outside the home designed to the capabilities of the residents The meals in the home are good, offering both choice and variety and also catering for special dietary needs EVIDENCE: The Care Manager stated that the residents are consulted regarding the dayto-day running of the home through residents meetings and by feedback from their key-workers, this was confirmed by the residents and minutes of the meetings. The key-workers also identify interests that the residents wish to pursue. A regular programme of musical evenings, board- games, sing-alongs, reminiscence group, quizzes and church services are organised within the home. Also the care manager has organised trips to the super market, garden centre and Ironbridge. The home has use of a Mini bus, which enables the staff to organises outings on the spur of the moment if the weathers fine. Seven of the residents went on holiday to Cornwall last summer. Most resident have good contact with their relatives and a good number of residents go out with their family on a regular basis. Family and friends are welcomed at the home and are invited to attend parties and other celebrations. Nelson Mandela House E56 000035973 Nelson Mandela House v229802 AI 200605 Stage 4.doc Version 1.30 Page 12 The observations made and the comments received from the residents and their relatives confirmed that particular attention is given to the resident’s individual preferences. However it was noted that a record of menus for Diabetics are not being kept. Nelson Mandela House E56 000035973 Nelson Mandela House v229802 AI 200605 Stage 4.doc Version 1.30 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 standard(s) 16 and 18 The home has a good complaints procedure with some evidence that resident’s views are listened and acted upon. The home has good policies and procedures regarding the protection from abuse, which includes a whistle blowing policy and the staff have a good understanding of their responsibilities. EVIDENCE: The home has a comprehensive complaints procedure. The residents and relatives are made aware of the procedure through the statement of their terms and conditions of residence and a notice on the notice board in the hall. The home has a complaints book in which all complaints are recorded. It was noted that the home has not received any formal complaints since the last inspection all minor complaints are dealt with appropriately and quickly. The home has good policies and procedures regarding Restraint, dealing with Aggressive Behaviour and Prevention of Abuse, which, includes a WhistleBlowing policy. These issues are also covered in the N.V.Q. training, which the Staff is undergoing. There have been no incidents that have needed to be recorded or reported. Nelson Mandela House E56 000035973 Nelson Mandela House v229802 AI 200605 Stage 4.doc Version 1.30 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 standard(s) 19 and 26 The standard of the environment within the home is high providing the residents with a very attractive, comfortable, homely and safe place to live. The garden and grounds are in need of care and attention and paths cleared and weeded. The home was found to be clean tidy and free of unpleasant odour. EVIDENCE: The home is long established purpose built home which provides appropriate accommodation for older people. The home is maintained to a good standard and provides a comfortable homely and safe atmosphere. It was noted that 9 residents’ bedrooms have been redecorated since the last inspection, 4 bedrooms have new floor covering and the corridors in Chillington and Wenlock units and been redecorated. The residents bedrooms have been personalised with the residents’ own personal possessions. This gives the appearance of a very comfortable environment. Nelson Mandela House E56 000035973 Nelson Mandela House v229802 AI 200605 Stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29, and 30 The home is well staffed with adequate numbers and skill mix of staff. The staff have a very good understanding of the residents’ support needs this is evident from the positive relationships which have been formed between staff and residents. The home has good policies and procedures regarding the recruitment of staff which include all the appropriate staff checks and references. However the home is not keeping a record of these checks on site. There is a very good training programme in place that ensures that the staff are competent to do their job. EVIDENCE: The inspection of staff rotas and discussions with staff indicated that the home is well staffed at all times. There is a good balance within the staff group, which includes experience, mature and younger staff who are embarking on a new career. It was noted that the Care Manager and her assistants are increasingly tied down by administration. The provision of a clerical assistant would be of great benefit allowing them to have more contact with the staff and residents. The Care Manager and staff are committed to developing their knowledge and skill through training. The home has a good induction programme and training programme, which meets the T.O.P.S.S standards. In addition to the N.V.Q training programme staff have attended training courses on the following subjects. Manual handling and lifting, Fire prevention, First Aid and Basic Food Nelson Mandela House E56 000035973 Nelson Mandela House v229802 AI 200605 Stage 4.doc Version 1.30 Page 16 Hygiene, Positive Approaches to Dementia Care and Safe Handling of Medication. The Local Authority is registered in order to complete the appropriate checks on staff. There was no evidence within the home that all the checks are being carried out. Nelson Mandela House E56 000035973 Nelson Mandela House v229802 AI 200605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 37, and 38 The routines and activities within the home are flexible and are built around the needs of the residents. The home is operating a good system to assist residents with the safe handling and keeping of their personal finances and good records are being kept of all transactions made. All the general records that was inspected, were found to be well ordered and maintained. The home has good policies and procedures regarding Health and safety and the care manager and staff demonstrated that they are aware of their responsibilities to promote health and safety. In regards to accidents these have been minimal and dealt with appropriately. EVIDENCE: The routines and activities within the home are flexible and built around the needs of the residents. There was also evidence to show that staff, consult with the residents’ regarding the choice of meals and activities within the Nelson Mandela House E56 000035973 Nelson Mandela House v229802 AI 200605 Stage 4.doc Version 1.30 Page 18 home. There are regular resident unit meetings where residents are consulted about menus and entertainment etc. Also the Key-Worker system in operation is designed to ensure residents’ wishes are responded to. The home is operating a good system to assist residents’ with the safe handling and keeping of their personal finances and good records are being kept of all transactions made. All the records and administrative procedures within the home that was, inspected were found to be well ordered and maintained. . However it was noted that the regulation 26 visits are not being carried out. The home has a good heath and safety policy and all staff are aware of their responsibilites regarding these issues and all of staff have received training. Nelson Mandela House E56 000035973 Nelson Mandela House v229802 AI 200605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 3 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 Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x 3 3 Nelson Mandela House E56 000035973 Nelson Mandela House v229802 AI 200605 Stage 4.doc Version 1.30 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 OP 29 Regulation schedule 2 Requirement A method of recording references, medicals and CRB checks must be developed as files are kept centrally off site.(Timescale of 31/03/05 not met) The Registered person must ensure that the Home has an effective system of Quality Assurance. This must include regulation 26 visit undertaken monthly.(Timescale of 31/03/04 not met The registered person must ensure that the gardens and grounds are maintained. Timescale for action 01/08/05 2. OP 34 24 01/08/05 3. 19 23 01/08/05 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. Refer to Standard 27 Good Practice Recommendations The registed person should provide the home with a part time clerical assistant. Nelson Mandela House E56 000035973 Nelson Mandela House v229802 AI 200605 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 2nd Floor, St. Davids Court Union Street Wolverhampton WV1 3JE 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 Nelson Mandela House E56 000035973 Nelson Mandela House v229802 AI 200605 Stage 4.doc Version 1.30 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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