Inspection on 29/09/05 for NUMAST Mariners` Park Care Home

This inspection was carried out on 29th September 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

NUMAST Mariners` Park Care Home 19/11/08

NUMAST Mariners` Park Care Home 23/08/06

NUMAST Mariners` Park Care Home 27/02/06

NUMAST Mariners` Park Care Home 01/03/05

NUMAST Mariners` Park Care Home 12/08/04

NUMAST Mariners` Park Care Home 17/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE NUMAST Mariners Park Care Home Royden Avenue Mariners Park Wallasey Wirral CH44 OHN Lead Inspector Les Hill Unannounced 29 September 2005 09:30 am 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. NUMAST Mariners Park Care Home F52 F02 S32407 Numast_Mariners Park V254333 290905 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service NUMAST Mariners Park Care Home Address Royden Avenue Mariners Park Wallasey Wirral CH44 0HN 0151 3346 8870 0151 346 8801 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) Numast Welfare Funds Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places NUMAST Mariners Park Care Home F52 F02 S32407 Numast_Mariners Park V254333 290905 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Receipt of satisfactory enhanced Criminal Records Bureau Disclosure for the person registered and registered manager. 32 beds nursing / 32 beds personal care in an overall total of 32 One (1) named male service user under 65 years of age in an overall number of 32(OP) Date of last inspection 1st March 2005 Brief Description of the Service: NUMAST, Mariners Park Care Home is a purpose built nursing and care home registered for 32 older people. It is owned and managed by NUMAST Welfare Fund, a registered charity that aims to provide a high quality, cost effective welfare service to seafarers and their families. The care home gives priority to ex seafarers, particularly those who have served in the merchant navy and families but will accept other residents if there are vacancies. It is located in the Mariners Park retirement complex in Wallasey. The premises have been constructed to a good standard and overlook the River Mersey. Local amenities such as shops and churches are located locally, in Wallasey or Liscard town. Residents accommodation is provided on two floors and has been completed to a good specification. All bedrooms are spacious single rooms with en-suite WC, wash hand-basin and shower. Communal rooms are spacious and an outside patio commands good views of the river and its shipping traffic. Car parking is provided at the front of the home and local transport is easily accessible. NUMAST Mariners Park Care Home F52 F02 S32407 Numast_Mariners Park V254333 290905 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of NUMAST Mariners Park care home was undertaken on Thursday 29th September 2005 by two inspectors from the Commission. It took place over a period of 6.5 hours and involved the examination of some records, a tour of the building and meeting with five residents. The inspection was undertaken as part of the Commission’s responsibility to visit and report on each registered care home on two occasions each year. What the service does well: What has improved since the last inspection? No recommendations were made at the last inspection. Two requirements have been repeated and are included below. NUMAST Mariners Park Care Home F52 F02 S32407 Numast_Mariners Park V254333 290905 Stage 4.doc Version 1.30 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. NUMAST Mariners Park Care Home F52 F02 S32407 Numast_Mariners Park V254333 290905 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 NUMAST Mariners Park Care Home F52 F02 S32407 Numast_Mariners Park V254333 290905 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) 1, 2, 3, 5 and 6. Prospective residents have the information they need to make an informed choice about the home. EVIDENCE: The Statement of purpose and service users guide have been incorporated into one document and are available to service users and visitors to the home. The documents contain all of the matters required in Schedule 1 and in Standard 1.2 of the National Minimum Standards, Care Homes for Older People. The documents are regularly updated and the organisation’s Deputy Director of Welfare Services agreed to consider separating the documents when they are next reviewed to introduce a more “resident friendly” guide to the home. All of the residents have a contract/terms and conditions of residence that identify what the home will provide, the fees and how these will be paid. Financial information is kept separate from the day-to-day care files used by staff. Pre-admission documents were being completed but they were not always located on the resident’s file. The home has also recognised that the NUMAST Mariners Park Care Home F52 F02 S32407 Numast_Mariners Park V254333 290905 Stage 4.doc Version 1.30 Page 9 documents do not provide them with all the essential information they need to prepare a plan of care. The inspectors agreed that the documents were in need of review. A member of staff has been working hard to prepare a new assessment tool and a blank copy was available during the inspection. The inspectors recognised that the home provides nursing care to a number of residents but felt that some elements of the new documentation were more appropriate for hospital settings. Inspectors advised the home’s managers to ensure that when the document is introduced it is relevant to the work they undertake with both nursing and personal care residents and the information gained is in a format that is useful for staff. The home is expecting to introduce the assessment tool for all residents within the next four months. The outcomes will be discussed at the next CSCI inspection. Visits to the home from prospective residents and their families are encouraged. A six-week trial period stay is offered to all new residents and information regarding the arrangements is included in the contract. The home is not contracted to provide Intermediate Care. NUMAST Mariners Park Care Home F52 F02 S32407 Numast_Mariners Park V254333 290905 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, 10 and 11. Care plans didn’t always show clear links to the assessment. Improvements to the recording of medicines were needed. EVIDENCE: As with the introduction of a new assessment tool, the home is to introduce new care planning documentation. Resident’s files contained assessment documents for continence, nutrition, moving and handling etc but it was not always clear how the outcomes had been developed into care plans. The Deputy Director of Welfare Services and the home’s manager were confident that the new documentation would provide them with the care planning and review information they need to guide staff in their work with individual residents. The inspectors look forward to examining the documents when they are in place but would again advise that they should be relevant to the needs of residents in a care home. None of the current residents has a pressure sore. NUMAST Mariners Park Care Home F52 F02 S32407 Numast_Mariners Park V254333 290905 Stage 4.doc Version 1.30 Page 11 Resident’s files confirmed contact with other healthcare professionals. The home has good links with a number of GP’s in the area and works closely with the tissue viability and continence adviser when appropriate. The home has policies and procedures in place for the administration of medicines. The CSCI inspection report in March 2005 identified that there were “Some minor discrepancies and blank spaces” in the Medicine Administration Records (MAR). The same problems were identified during this inspection. The organisation must provide training and professional supervision to ensure that its qualified nurses maintain accurate records of the administration of medicines in the home. Mariners Park has appropriate contract arrangements in place for the disposal of unused medicines. A policy and procedure should now be introduced to ensure the safe denaturisation of controlled drugs. Some of the residents are able to manage their own medicines. Where this was happening the home had undertaken a risk assessment and a lockable facility was provided in their bedroom. Each resident has a single room with en-suite WC and shower facilities. Personal care is given in their own bedrooms or in one of the bathrooms as appropriate. Residents can choose to meet with visitors in their own room or in one of the communal spaces around the home. The home has policies and procedures in place that support the principles of privacy and dignity and staff were seen to knock on bedroom doors before entering. The home confirms with residents and/or their families their wishes at the time of death and these are recorded on the residents file. The home’s policies and procedures expect that residents at the latter stages of their life, will be treated with dignity and respect. NUMAST Mariners Park Care Home F52 F02 S32407 Numast_Mariners Park V254333 290905 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14 and 15. Residents are helped to exercise choice and control over their lives. EVIDENCE: An activities organiser has been appointed to work in the home. Inspectors met with her and were impressed with her enthusiasm and the ways in which she had encouraged residents to agree to join in activities and trips out from the home. The activities organiser planned to carry out some individual work with residents as well as involving them in the group activities she had arranged. One of the lounges in the home is used for activities and was equipped with five computers. Residents can choose to have their own e-mail address and some of them communicate with family and friends through the Internet. These facilities are also available to residents of the organisations sheltered accommodation located on the same site as the care home. Sheltered accommodation residents are also invited to some of the group activities planned in the home. Links are being made with merchant navy groups and shipping companies to further the development of interests and the support of residents in Mariners Park. NUMAST Mariners Park Care Home F52 F02 S32407 Numast_Mariners Park V254333 290905 Stage 4.doc Version 1.30 Page 13 Visitors to the home are welcome at any time and residents from the home will often visit friends who live in the Mariners Park complex. Residents can choose what times they get up and go to bed each day and whether or not they join in activities. They can also choose whether to spend time in the communal rooms or to spend time in their own rooms. Small kitchenette areas are provided in each of the lounge areas where they or their visitors can make a drink. Chefs at the home spend time with individual residents to ascertain their likes and dislikes for foods and drinks and establish any particular dietary requirements. Residents have a choice at mealtimes. The main meal is served at lunchtime and there is a choice of three starters, three main courses and three puddings. The menu is reviewed on a regular basis and any changes required are implemented. Food being served at the time of this inspection was well prepared and served. Residents who commented about the food were complimentary about the range and quality of the meals. NUMAST Mariners Park Care Home F52 F02 S32407 Numast_Mariners Park V254333 290905 Stage 4.doc Version 1.30 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 standard(s) 16, 17 and 18. Residents are protected from abuse. EVIDENCE: The home has a complaints policy and procedure in place that is available to residents and includes contact details for CSCI. Three complaints had been received in the past twelve months and all of them had been responded to appropriately. The inspectors discussed the organisation of the complaints log to ensure they could be more easily referenced. All of the residents are listed on the Electoral register and are eligible to vote in local and national elections. Policies and procedures are in place to support staff in raising concerns and in dealing with allegations of abuse. The new manager at the home had recently attended a training course on the POVA Requirements and will be cascading the information to other staff. NUMAST Mariners Park Care Home F52 F02 S32407 Numast_Mariners Park V254333 290905 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. Residents live in a safe and well-maintained environment. EVIDENCE: Mariners Park is a purpose built care home that is fully accessible to people in wheelchairs. Corridors are wide and communal rooms have large windows many of which overlook the River Mersey. A large deck area is accessible from two of the lounges and again overlooks the river. The home has large communal spaces that are situated throughout the home. One of the lounges is designated as a smoking room and two of the lounges (one on each floor) are also used for dining. Another communal space is designated as an activities room where residents of the home and residents of the sheltered accommodation on site can meet for individual and group events, and use the computers. NUMAST Mariners Park Care Home F52 F02 S32407 Numast_Mariners Park V254333 290905 Stage 4.doc Version 1.30 Page 16 All of the bedrooms have en-suite facilities that include a WC, wash hand-basin and walk-in shower. Additional WC’s are located throughout the building and there are large bathrooms with specialist bathing equipment. The home is equipped with a range of hoists, grab rails, adjustable beds, armchairs and pressure relieving mattresses. Any specialist equipment for individual residents is requested through the appropriate Occupational Therapy assessment. All of the Resident’s bedrooms are single rooms but some have adjoining doors and married couples or friends who wish to share a room can use one as a bedroom and another as a sitting room. Residents are encouraged to bring items from home to personalise their own rooms. All of the bedrooms are fitted with a lock and residents can choose to hold their own key. The care home is well heated and ventilated. A computer monitors the heating system but residents are able to adjust the temperature in their own room within a range of 4 degrees centigrade. Windows in the communal areas are large and allow natural light to pervade the room. All rooms have windows that can be opened and they are fitted with appropriate safety devices. Infection control policies and procedures are in place. On the day of this inspection there were no offensive odours noted in any part of the home. NUMAST Mariners Park Care Home F52 F02 S32407 Numast_Mariners Park V254333 290905 Stage 4.doc Version 1.30 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 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. Residents are supported and protected by the home’s recruitment and selection practices. EVIDENCE: The home employs 9 trained nurses, 21 care staff and 10 ancillary staff. It has its own “bank” staff to cover sickness and holidays but has also needed to use some agency workers. Seven care staff currently hold an award at NVQ level 2 or above, in care. A further six staff are in the process of training for the award. If four of those staff can be awarded an NVQ at level 2 by the end of 2005 the home will have achieved the target standard. A sample of staff files were examined and found to contain all the essential information required. There was also evidence to confirm that an induction process had been completed. However there was some confusion about the storage of CRB clearance documents. Staff were advised that they should record the date a CRB clearance form had been returned and the identification number, on the staff file. The form itself should be managed as per the instructions given out by the CRB authorities. All new staff are required to undertake both induction and foundation training to TOPPS standards. Qualified nurses are assisted with their on-going professional development and training. All staff are trained in food hygiene, NUMAST Mariners Park Care Home F52 F02 S32407 Numast_Mariners Park V254333 290905 Stage 4.doc Version 1.30 Page 18 fire prevention and moving and handling. Copies of any certificates earned by members of staff are kept on their file. The home is developing a computerised record of training provided to each member of staff. NUMAST Mariners Park Care Home F52 F02 S32407 Numast_Mariners Park V254333 290905 Stage 4.doc Version 1.30 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 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) 31, 33, 34, 35 and 36, The home is run in the best interests of residents. EVIDENCE: The organisation has appointed a new manager who is yet to submit an application for registration to CSCI. The new manager has only been in post for approximately three months and therefore it is difficult to assess at this point, her impact upon the atmosphere within the home. The home has an “Investors in People” award. Previous inspection reports have reported that quality-monitoring audits are undertaken on a regular basis and that residents are asked to complete a questionnaire to assist the home’s managers to assess the quality of care provided. NUMAST Mariners Park Care Home F52 F02 S32407 Numast_Mariners Park V254333 290905 Stage 4.doc Version 1.30 Page 20 Records required by regulation will be examined at the next inspection. The organisation managing Mariners Court is registered with the Charities Commission and as such must provide factual information about its financial performance. In addition the organisation arranges its own annual audit of accounts. The Commission is not aware of any matters that would question the financial viability of the home. The individual financial affairs of residents are managed by themselves, their families, their advocates or by the placing local authority. Small amounts of money are held by the home for some of the residents. An examination of the records for these small amounts was undertaken at the previous CSCI inspection and the arrangements were in good order. The organisation’s Deputy Director of Welfare Services makes regular and frequent visits to the home. She attended towards the end of the inspection to receive feedback from the day’s findings. It was clear that she was fully au-fait with the day-to-day workings of the home and gave her support to the new manager in correcting matters identified during the inspection. The new manager told the inspectors that she supervises the trained nurses and that they in turn supervise the care staff. There was evidence on the staff files examined of supervision having taken place. NUMAST Mariners Park Care Home F52 F02 S32407 Numast_Mariners Park V254333 290905 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION 4 4 4 4 4 4 4 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 2 3 3 3 3 3 x x NUMAST Mariners Park Care Home F52 F02 S32407 Numast_Mariners Park V254333 290905 Stage 4.doc Version 1.30 Page 22 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 OP9 Regulation 8 Requirement An application must be submitted to CSCI for the newly appointed manager to be registered. Staff must adhere to the policy and procedure for the recording of medicines administered to residents (previous time scale of 01/03/05 not met). Timescale for action 27/10/05 2. OP31 8 29/09/05 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. 2. Refer to Standard OP3 OP7 Good Practice Recommendations The homes manager should ensure that the new assessment documentation is relevant and appropriate for the needs of residents admitted to the home. The homes manager should ensure that care plans produced from the new assessments documentation are relevant and appropriate for the needs of residents admitted to the home. The homes manager should develop a policy and procedures for the denaturisation of Controlled Drugs. The organisation should develop a system for managing the results of CRB clearance applications. F52 F02 S32407 Numast_Mariners Park V254333 290905 Stage 4.doc Version 1.30 Page 23 3. 4. OP9 OP29 NUMAST Mariners Park Care Home Commission for Social Care Inspection Liverpool Area Office 3rd Floor 10 Duke Street Liverpool, L1 5AS 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. 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