Inspection on 04/10/05 for Nelson Mandela House

This inspection was carried out on 4th October 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 20/06/05

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 West Midlands WV9 5NJ Lead Inspector Mr Ian Harris Unannounced Inspection 4th October 2005 09:00 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 Nelson Mandela House DS0000035973.V255425.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. Nelson Mandela House DS0000035973.V255425.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Nelson Mandela House Address Whitburn Close Pendeford Wolverhampton West Midlands WV9 5NJ 01902-553462 01902-553468 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) Wolverhampton City Council Mrs Sylvia Beverley Campbell Care Home 37 Category(ies) of Dementia (8), Mental disorder, excluding registration, with number learning disability or dementia (8), Old age, not of places falling within any other category (29) Nelson Mandela House DS0000035973.V255425.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 50 years and above Kinver unit 8 residents category DE, MD only with no number division between categories 20th June 2005 Date of last inspection 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 users 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 DS0000035973.V255425.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 5 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 and one relative were spoken to. 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: What has improved since the last inspection? Since the last inspection the work in the garden and grounds has been carried out which has made a great improvement. Also regulation 26 visits to the home are now being carried out. Nelson Mandela House DS0000035973.V255425.R01.S.doc Version 5.0 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. Nelson Mandela House DS0000035973.V255425.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 Nelson Mandela House DS0000035973.V255425.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): 4 and 5 The home provides clear and accurate information to prospective residents on the services provided, enabling them to make a properly informed choice about the home. All residents are given a written contract on admission to the home. EVIDENCE: Each resident is provided with a detailed service users guide and statement of terms and conditions when they move into the home. This statement contains all the required information. The statement is clear on what the fees do and do not cover. Residents are encouraged to visit the home prior to admission. An introductory visit is always offered to prospective residents, on some occasions the visits are declined and relatives visit on behalf of the prospective resident prior to admission in order for them to make an informed decision. A review is held after about six weeks after admission, where the resident and family are invited to ensure all needs are being met. A trial period is included in the statement of terms and conditions of residence and the homes contracts. Nelson Mandela House DS0000035973.V255425.R01.S.doc Version 5.0 Page 9 Nelson Mandela House DS0000035973.V255425.R01.S.doc Version 5.0 Page 10 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): 9 and 11 Staff are sensitive to the individual needs of each service user and meet these in a professional manner The home has good contact with local G.P. s. local hospitals and paramedical services, which ensures that residents’ health needs are met. The systems for the administration of medication are good with clear and comprehensive recording arrangements in place to ensure resident’s medication needs are met. EVIDENCE: The home is well supported by local G. P.’s and all paramedical services. Where possible the residents are encouraged to retain their own G. P.’s, Dentists and Opticians. However if a resident has moved outside of their area, the Care Manager ensures, that these services are provided by local practitioners. Medication is administered by means of a monitored dosage system. The system is working well. The home receives good support from the local pharmacist who carries out a three monthly audit. All Senior Care Staff are Nelson Mandela House DS0000035973.V255425.R01.S.doc Version 5.0 Page 11 trained in the system before they are allowed to administer medication. The home has comprehensive policies and procedures, which are an integral part of the homes staff induction programme. Residents’ wishes with regard to terminal care and arrangements after death are obtained at the assessment stage, if possible. Family members are involved in these discussions if appropriate. Unless there are medical reasons for not doing so, service users are able to spend their final days in their own rooms. Where the needs of service users change, re-assessments are requested. The home has clear policies with regard to dying and death. The Care Manager and Care Staff are conscious of the need to provide extra support to the residents in their final days at the home. All the Staff are very aware of the need to be particularly sensitive, caring and attentive to the residents needs prior to their death. The care manager is also aware of the support the staff should provide to relatives and colleagues. Resident’s relatives are encouraged to be fully involved in the residents care at this particular time. Care staff receive training in care of the dying and the bereaved through N.V.Q. Nelson Mandela House DS0000035973.V255425.R01.S.doc Version 5.0 Page 12 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 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 staff and the residents who could express themselves in a meaningful way stated the residents are consulted regarding the day-to-day running of the home through residents unit meetings and by feedback from their keyworkers. 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 the use of a Mini bus, which enables the staff to organise outings on the spur of the moment if the weathers fine. The observations made and the comments received from the residents confirmed that particular attention is given to the resident’s individual Nelson Mandela House DS0000035973.V255425.R01.S.doc Version 5.0 Page 13 preferences regarding meals. The home has produced very attractive and clear menus. Nelson Mandela House DS0000035973.V255425.R01.S.doc Version 5.0 Page 14 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): 17 All residents are assisted to exercise their legal rights, either by family, staff or where appropriate by an advocate provided by Care Aware. EVIDENCE: Residents are assisted to exercise their legal rights, either by family, staff or where appropriate an advocate provided by Care Aware. All permanent residents are registered on the electoral register to vote. They may vote if they wish either by post, or they are assisted to go to the polling station if this is requested and most residents voted in the last general election. Nelson Mandela House DS0000035973.V255425.R01.S.doc Version 5.0 Page 15 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 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 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 this year, 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. The home was found to be clean and tidy and free from odour. The home has good policies and procedures regarding infection control and all the staff have Nelson Mandela House DS0000035973.V255425.R01.S.doc Version 5.0 Page 16 received training in food hygiene dangers of cross infection. All staff appeared to be conscious of the Nelson Mandela House DS0000035973.V255425.R01.S.doc Version 5.0 Page 17 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, 29 and 30 The home is not always staffed to a level that ensures that service users’ needs are met at all times. The home has good policies and procedures regarding the recruitment of staff, which includes all the appropriate staff checks and references. 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 understaffed at times and does not meet the needs of the residents, particularly in the afternoons. The practise of having one care staff covering a unit and one person floating is not enough. During the inspection it was observed that a unit was left without any staff for twenty minutes. A visitor to the home who was present stated it was upsetting to see the residents just sitting without any stimulation. A number of residents expressed very positive comments regarding the staff- including “ nothing is too much trouble” “ they look after us well here” However they also said they are rushed off their feet and they have to work hard. The home operates an efficient recruitment procedure and the Local Authority has registered with the Criminal Records Bureau in order to complete the appropriate checks on staff. However there is still no evidence within the home that all the checks are being carried out. The Care Manager and staff are committed to developing their knowledge and skill through training. The home has a good induction programme and training Nelson Mandela House DS0000035973.V255425.R01.S.doc Version 5.0 Page 18 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 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. The C.R.B. checks are being carried out centrally However there was no evidence within the home that all the checks are being carried out. Nelson Mandela House DS0000035973.V255425.R01.S.doc Version 5.0 Page 19 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): 33 and 35 The home is well managed, where service users interests and welfare are well processed and promoted. The systems for resident consultation are good with evidence suggesting that their views are sought and acted upon Residents’ finances are being handled appropriately by designated senior staff. 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 as much as possible regarding the choice of meals and activities within the home. There are regular resident unit meetings where residents are consulted about menus and entertainment etc. Also the KeyWorker 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 Nelson Mandela House DS0000035973.V255425.R01.S.doc Version 5.0 Page 20 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. Nelson Mandela House DS0000035973.V255425.R01.S.doc Version 5.0 Page 21 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 x 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 3 18 x 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x 3 x x x Nelson Mandela House DS0000035973.V255425.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? YES 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 27 Regulation 18 (1) (a) Requirement The registered person must ensure that the care staff hours are increased in order to provide a minimum of 2 care staff on duty in each unit throughout the working day and in addition 1 floating care staff throughout the day to assist in the unit as required 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) Timescale for action 01/12/05 2 OP 29 Schedule 2 01/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Nelson Mandela House DS0000035973.V255425.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Wolverhampton Area Office 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 DS0000035973.V255425.R01.S.doc Version 5.0 Page 24 - 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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