Inspection on 07/08/06 for Nelson Mandela House

This inspection was carried out on 7th August 2006.

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 04/10/05

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 Key Unannounced Inspection 7th August 2006 08:00 07/08/06 08:00 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.V297424.R01.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. Nelson Mandela House DS0000035973.V297424.R01.S.doc Version 5.2 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) www.wolverhampton.gov.uk Wolverhampton City Council 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.V297424.R01.S.doc Version 5.2 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 4th October 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 currently being use for respite and short stay placements. There is limited carparking facilities at the front of the property and two enclosed garden areas. Nelson Mandela House DS0000035973.V297424.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and took place over 6. hours in the presence of the regulation manager. 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. 5 members of staff 8 residents and 4 relatives were spoken to. It was noted that the fees are set following an individual financial assessment undertaken by he Social service department. On the day of inspection the atmosphere within the home was found to be warm, friendly and comfortable with contented residents. All the residents spoken who could express themselves in a meaning full way expressed their satisfaction with the care they received and there were comments as follows “ the food is good here” “We are well looked after here” “ The staff are very good they are like family and 2 residents said “this is a very nice home.” However there was great anxiety expressed by the residents, relatives and staff about the future of the home and that it will be closed they all feel they are being kept in the dark. Two of the relatives stated that they could not understand the reason for closing a perfectly good home where their relatives are very happy. What the service does well: What has improved since the last inspection? The home is operating a maintenance programme that is only addressing health and safety issues until the future of the home is decided. Since the last inspection the emergency lighting has been renewed. All the kitchen units in the lounge dining room have been replaced and window locks have been fitted throughout the home. Nelson Mandela House DS0000035973.V297424.R01.S.doc Version 5.2 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.V297424.R01.S.doc Version 5.2 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.V297424.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 The statement of purpose does not reflect the service that is being provided by the home. The assessment procedures need to be revised in order to ensure the home can meet the needs of the residents. The home does not provide intermediate care. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: Since the closure of the O.M.I. unit the unit is being use for short stay, respite and emergencies placements some of which are inappropriate. They ranged from a person in they 50s with social problems to very elderly people and someone with M.S. There is evidence on the 6 files that were inspected that all the residents undergo a full multi-disciplinary assessment prior to admission. However it was noted that the criteria for admission for short stays and respite is not clear and must be decided and stated in the revised statement of purpose Nelson Mandela House DS0000035973.V297424.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Each resident has a very good 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 well met. The systems for the administration of medication are good with clear and comprehensive recording arrangements being in place to ensure resident’s medication needs are well met. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. 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 regular basis. Four residents were case tracked and the records indicated that they are Nelson Mandela House DS0000035973.V297424.R01.S.doc Version 5.2 Page 10 receiving appropriate care this was confirmed by the residents who said they were happy and well cared for. 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 these services, are provided by local practitioners. The records indicate that resident’s medical needs are being met. Medication is administered, by means of a monitored dosage system in three of the units. The residents in the short stay / respite unit are encouraged as part of their care plan to self medicate under supervision. 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 Senior Staff have been trained to use the system before they are allowed to administer medication. The home has very good policies and procedures, which are used as guidance and are an integral part of the care staff induction programme. Nelson Mandela House DS0000035973.V297424.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, and 15 The home provides a good programme of social activities within the home, which are designed to meet the resident’s capabilities, which, the staff encourage residents to pursue. However it was noted that there is very little take up by the residents and no outings have been provided this year. The Care Manager and staff encourage family and friends to maintain good contact with their relatives at the home. The meals in the home are good offering both choice and variety and also catering for special dietary needs. The quality outcome in this area is adequate. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The home has a staff member designated to organise social and leisure activities and who identified interests that the residents wish to pursue. However the shortage of care staff has meant that there is very little on offer in the way of stimulating activities even though there is assess to the day centre and transport available. It was also noted the lack of shopping trips or outings outside of the home were not taking place. This could be directly due to lack of staff availability. Nelson Mandela House DS0000035973.V297424.R01.S.doc Version 5.2 Page 12 The staff at the home encourage relatives and friends to maintain good contact with the residents and during the inspection there were many visitor in the home and three confirmed that they are always made welcome when they visit the home. They also stated that this was a very good home and particularly with good caring staff and could not understand why the council are considering closing it. The observations made, examination of menus and the comments received from the residents and relatives confirmed that there is a good choice at meal times and particular attention is given to the residents’ individual preferences. Nelson Mandela House DS0000035973.V297424.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has a satisfactory complaints system and there is evidence that residents’ and their families feel that their views are listened to and acted upon The home has good policies and procedures regarding protection from abuse, which includes a whistle blowing policy. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The home has a very good comprehensive complaints procedure. The residents and relatives are made aware of the procedure through the statement of their terms and conditions of residence, the service users guide and, which a copy is issued on admission to the home. Also a copy is placed in the reception 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 internal and N.V.Q. training, which all care Staff is undergoing. Nelson Mandela House DS0000035973.V297424.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The standard of the environment within the home is adequate providing the residents with a comfortable, homely and safe place to live. The home was found to be clean tidy and free of unpleasant odour. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The home is long established purpose built home which provides appropriate accommodation for older people. However it has become dated to to-days standards and does not provide en-suite facilities to the bedrooms. The home is maintained to a good standard and provides a comfortable homely and safe atmosphere. It was noted that the trees and shrubs in the grounds are overgrown and is blocking out the day light to a number of bedrooms making them dark and gloomy. Also there is a number of outstanding repairs in the kitchen that must be addressed. Nelson Mandela House DS0000035973.V297424.R01.S.doc Version 5.2 Page 15 The home was found to be clean and tidy and free from odour. The home has good policies and procedures regarding infection control and the staff have received training in food hygiene and Infection Control. From observations and discussions with staff they appeared to be conscious of the dangers of cross infection. Nelson Mandela House DS0000035973.V297424.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, and 30 The home must improve the staff levels with adequate numbers and skill mix of staff to meet the needs of the residents. The staff have a very good understanding of the resident’s support needs but are pressurised. The home has good policies and procedures regarding the recruitment of staff, but should be reviewed to ensure all the staff record contain the required documentation.. There is a excellent training programme in place that ensures staff are competent to do their job. The quality outcome in this area is adequate. This judgment has been made using available evidence including a visit to this service. EVIDENCE: Inspection of staff rotas and discussions with staff indicated that the home is understaffed at times and does not always meet the needs of the residents. There has been a high turnover of care staff, and sickness absents recently, which had meant that agency staff are being used for cover. On the day of inspection the home has 4 care staff vacancies, 1 night care and 2 managers on long term sick. The rota indicates that there are only 6 care staff on duty to cover 4 units which means that the 2 units have only 1 member of staff covering it. This is a particular concern given the high dependency of a number of residents, the lack of stimulation and the responsibility to use 2 staff members to administer medication. This creates a situation when units are left uncovered by care staff. Also since the closure of the O.M.I. unit the home has Nelson Mandela House DS0000035973.V297424.R01.S.doc Version 5.2 Page 17 been used for short stays, respite and emergency admissions, which has generated a lot more work for the staff. The staffing levels within the home should be reviewed as a matter of urgency. The staffing should be increased to ensure a minimum of 2 care staff to each unit and I floating member of staff to concentrate on the administration of medication. The home operates an efficient recruitment procedure and the local Authority has registered in order to complete the appropriate checks on staff. However there was no evidence within the home that all the checks are being carried out. It was also noted that the process is very lengthy and causes long delays before a newly recruited staff member can start work. In regards to staff files it was noted that they do not have copies of a passport or a current photograph. The home has a good induction programme and training programme, which meets the Skills for Caring 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. Nelson Mandela House DS0000035973.V297424.R01.S.doc Version 5.2 Page 18 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, and 38 The home is well managed, where service users interests and welfare is promoted. 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. The records that were inspected, were found to be well ordered and maintained. The home has good policies and procedures regarding Health and safety. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The home is without a Registered Manager however the Acting Care Manager is qualified in both practice and management and has considerable experience in caring for older people in residential homes. These interim arrangements are satisfactory are have been agreed with by the Commission. There are clear Nelson Mandela House DS0000035973.V297424.R01.S.doc Version 5.2 Page 19 lines of accountability within the home and is very supportive of both staff and residents. Observations made and discussions with residents’, relatives and staff indcated that the Care Manager is very approachable and operates an open door policy. The staff and residents who could express themselves stated that they are happy to approach the Care Manager and staff with any problems they might have and were confident that they would be responded to. All the Financial records and administrative procedures within the home that were, inspected were found to be well ordered and maintained. The home has a good heath and safety policy and all staff are aware of their responsibilities regarding these issues and a number of staff have received training on these issues. All safety equipment is check and well maintained. Nelson Mandela House DS0000035973.V297424.R01.S.doc Version 5.2 Page 20 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 2 X 2 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Nelson Mandela House DS0000035973.V297424.R01.S.doc Version 5.2 Page 21 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 OP29 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 gardens and grounds are maintained. 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 The registered person must ensure that The statement of purpose is revised to reflect the recent change. The registered person must revise the criteria for admission for short stays and respite. and add it to the revised statement of purpose Timescale for action 01/09/06 2. 3 OP19 23 18 (1) a 01/09/06 01/10/06 OP27 4 OP1 5 OP3 4 (1) 01/09/06 4 (1) 01/09/06 Nelson Mandela House DS0000035973.V297424.R01.S.doc Version 5.2 Page 22 6 OP19 23 (2) ( c) The register person must ensure that the broken dishwasher and tray in the kitten is replaced or repaired. 01/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Nelson Mandela House DS0000035973.V297424.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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.V297424.R01.S.doc Version 5.2 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. 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