Inspection on 18/10/05 for Rushey Mead Manor

This inspection was carried out on 18th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Rushey Mead Manor 05/10/09

Rushey Mead Manor 07/04/09

Rushey Mead Manor 14/01/09

Rushey Mead Manor 10/09/08

Rushey Mead Manor 02/10/07

Rushey Mead Manor 12/12/06

Rushey Mead Manor 03/05/06

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Rushey Mead Manor 30 Coatsbridge Avenue Leicester LE4 7TZ Lead Inspector Keith Charlton Unannounced Inspection 18th October 2005 10:00 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 Rushey Mead Manor DS0000064260.V258521.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. Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Rushey Mead Manor Address 30 Coatsbridge Avenue Leicester LE4 7TZ 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) 02476 332782 Midland Healthcare Ltd Mrs Linda Moody Care Home 40 Category(ies) of Dementia (17), Mental disorder, excluding registration, with number learning disability or dementia (17), Old age, of places not falling within any other category (40), Physical disability over 65 years of age (5) Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person falling withing category PD(E) may be admitted to the Home when 5 persons of that category are already acommodated within the Home No person falling within category MD(E)/DE(E) may be admitted when 17 persons in total of these categories/combined categories are already accommodate 16/6/2005 Date of last inspection Brief Description of the Service: Rushey Mead Manor is a forty-bedded residential care home for older persons. It has recently be taken over by Midland Healthcare who have indicated that all relevant issues will be reviewed and improved. The Home is situated in a multi-cultural area of the city. Shopping facilities are adjacent to the home. There are also local amenities within walking distance form the home.Bus services are situated around the corner from the property and run regularly into the town centre, which is a fifteen minute journey.The service users in the home represent the diversity of cultures within the local area.A large percentage of the staff group also represent the cultures of the service users. All religious and spiritual practices are supported and respected. Appropriate dietary requirements are catered for in that there are two distinct vegetarian and non vegetarian kitchens. Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service user and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting two service users and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This inspection took place over two days. There was an inspection of facilities, viewing records, policies and care plans and talking to staff and service users. Many of the service users were seen during the inspection and six service users, and one relative gave the inspector their views of the service. The inspection commenced at 9.35am and finished at 4.35pm and was completed on 20/10/2005. What the service does well: What has improved since the last inspection? An activities programme is in place to stimulate service users. Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 6 The Registered Provider is continuing to deal with facilities issues and décor and the replacement of windows to the first and second floors and there is a newly decorated dining room near the vegetarian kitchen that service users use. A large number of staff have completed National Vocational Qualification level 2 care training. 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 Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 7 contacting your local CSCI office. Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 8 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 Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 9 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): 1,2,3,6 Prospective service users have the information they need to make an informed choice of where they live and their needs are assessed. EVIDENCE: There is now a comprehensive Statement of Purpose outlining the home’s services and facilities. Service users contracts have been sent to representatives for signing. The Registered Manager said they would then be placed on file, accessible to service users and representatives. Assessments were in file for two service users files inspected. The Registered Manager is to review the assessment form based on information from the National Standard so that this is more comprehensive. A service user with sensory impairment was admitted outside the home’s Registration category. The Registered Provider needs to apply for a variation to legalise this situation. Intermediate care facilities are not provided. Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 10 Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 11 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): 7,8,9,10 Service users heath needs are not always protected or regularly reviewed. Proper respect to service users was in place with a number of exceptions. EVIDENCE: Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 12 Service users were again generally positive regarding the care they received and said that staff were respectful although one service user said that some staff were ‘sharp’ at times, that staff were not friendly and ignored her and that she had too wait too long for assistance to go to the toilet. Other service users said that they were well cared for – staff were seen to be generally friendly in their dealings with service users and a visiting relative said there were no problems with the care of her mother. There were observed occasions when staff were unintentionally patronising towards service users. The Registered Manager said she would follow up these issues. The Registered Manager has produced generally comprehensive care plans that are being reviewed so that information is more concise. A Care Plan was viewed which was based on the person centre model and which contained specific personal preferences – this was commended. Regular reviews have not yet commenced though the Registered Manager is in process of delegating this to senior staff. Records of turning charts were not always maintained for a service user. Accident records were inspected and found that staff had alerted medical services when needed by service users. However it was noted that service users had frequently fallen from wheelchairs - this needs to be followed up and a plan of action produced to prevent such accidents. Another accident was not recorded in the accident book or reported to the Commission for Social Care Inspection. Medication records were generally well recorded though there were occasions where there were gaps. Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 13 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): 12,13,14,15 Activities on the whole meet service users needs though regular outings need to be arranged. The food is well prepared though may not always be to all service users tastes. EVIDENCE: Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 14 There is now an Activities Programme and staff were observed to be playing games with service users. Service users said they were generally satisfied with this though there were also comments that service users would like more outings - to go to parks etc. The Company has employed someone with Asian language skills to provide religious activities for service users whose first language is not English or who are unable to speak English. This is much appreciated by service users. There are Asian television services available and Asian videos and there are more religious videos available. The Registered Manager has produced a programme of activities and this is recorded on a daily basis. Service users said that visitors were welcome - a relative confirmed this. Service users also confirmed that they could choose their lifestyle – when to get up and go to bed etc. Service users stated that the food was generally good. The Inspector tried samples of the English and Asian food and found they were tasty. The Registered Manager said that there was a complaint from some service users regarding the food on one occasion recently and from one family, which is being followed up at present. The home has two meal sittings where English and Asian food is offered. Fruit, snacks and beverages are supplied throughout the day and supper is now supplied - sandwiches and biscuits etc. Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 15 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): 16,18 Service users/their representatives can on the whole be confident their concerns will be properly attended to though all complaints need to be fully followed up. EVIDENCE: Service users said they felt safe in the home and they thought the Registered Manager would tale action if they told her their concerns. The Responsible Individual has a complaints policy and procedure, but needs to be clear that it states that complainants can go directly to the Commission for Social Care Inspection without first going to the Registered Manager. There is a complaints folder and the Registered Manager quickly followed up the last complaint made. Not all complaints expressed (a relative regarding care and service users regarding food) have been documented. All staff have received training on what constitutes abuse and the procedure on what to do in the event of abuse, and staff talked to were generally aware of which Agencies to contact in the event of abuse occurring. Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 16 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): 19,26 Facilities have been significantly improved and need further improvement complete this process. EVIDENCE: Service users said that they liked their bedrooms. Facilities are now generally odour free – three bedrooms were identified as needing attention due to accidents occurring. The home provides spacious accommodation in three lounges, two dining rooms and a quiet room. The Responsible Individual has ordered improvements to facilities and a number of areas have been attended to - the main lounge, main hallway and corridors, some bedrooms and dining room near the vegetarian kitchen have been decorated. Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 17 The décor is generally bright and clean in the service users’ bedrooms and a number have been redecorated. The following areas need to be dealt with – room 32, repair to the flat roofs over kitchen and main entrance and carpet replacements to 20,24,25 (where odour problems were identified). Windows on the first and second floors were being attended to at the time of the inspection. There are now adequate bathroom facilities, as showers are now floor draining and without steps up to them so are accessible to service users. Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 18 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 Staffing levels appear to generally meet service users needs though the recruitment process does not yet fully protect service users. EVIDENCE: Comments were received that because of language problems not all senior staff were able to respond to medication queries from service users and dealing with medical and medication issues. The Registered Manager is to follow this up to ensure Staffing levels within the home are in accordance with current requirements – the Registered Manager stated that there were normally six care staff on duty in the morning and five care staff on in the afternoon/evening plus three members of staff on waking night duty. There was a comment received that it was a struggle to care for service users at mealtimes as there were five service users who needed assistance to eat. For a Home of this size it would be expected that the Registered Manager has the support of a Deputy for when the occupancy level increases. A staff record inspected showed that this staff member from overseas commenced employment before a Protection of Vulnerable Adults check being in place. The Registered Manager has compiled a recruitment procedure. Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 19 Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 20 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): 35,38 Health and Safety systems do not fully protect the welfare needs of service users. EVIDENCE: Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 21 The new Responsible Individual has now submitted Regulation 26 Monthly Reports on the running of the Home. Service user finance records were inspected and found to be generally satisfactory though more detail is needed regarding receipts and staff signatures. There are currently no designated kitchen assistants as they have been redesignated to care duties. The Registered Manager must ensure that essential kitchen cleaning duties are carried out - a cook said that she was struggling to complete all essential duties even with help provided two days a week plus the handyman helping on occasion. The home has a policy outlining safe working practices and Risk Assessments in relation to areas of the home which may pose a Health & Safety risk to the home’s service users, e.g. access to the kitchen, the garden area, the stairs, window restrictors etc and the Registered Manager is to review these to include all known risks, e.g. service users access to personal hygiene products etc. Radiator covers need to be fitted in some areas to protect service users from hot surfaces. Unoccupied rooms on the first floor were open with objects on the floor that service users could have tripped over. The Registered Manager asked the handyman to keep these rooms locked. Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 22 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 3 3 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 23 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 OP3 Regulation 12 Requirement The Registered Provider must ensure that service users outside the Registration categories are not admitted. The Registered Manager needs to ensure a system of regular review for service users Care Plans. Service user health needs to be protected at all times. Medication must be given and recorded as proscribed. The Registered Manager is to follow up the comment that a staff member is curt and that staff always address service users with respect. The Registered Provider needs to ascertain service user wishes regarding outings and arrange a programme based on this information. All complaints need to be recorded and appropriately acted upon. Some aspects of facilities – roof repairs, décor and flooring odour problems need to be attended to. DS0000064260.V258521.R01.S.doc Timescale for action 27/10/05 2 OP7 15 20/11/05 3 4 5 OP8 OP9 OP10 12 12 12 20/10/05 20/10/05 27/10/05 6 OP12 16 20/12/05 7 8 OP16 OP19 22 23 20/10/05 20/12/05 Rushey Mead Manor Version 5.0 Page 24 9 10 OP29 OP38 19 13 All essential statutory checks must be in place before staff commence employment. All aspects of Health and Safety need to be fully in place – Risk Assessments for safe working practices, radiator covers etc. 27/10/05 27/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP27 Good Practice Recommendations The Registered Provider is strongly recommended to appoint a Deputy Manager to support the Registered Manager in her duties when numbers of service users accommodated increases. Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Rushey Mead Manor DS0000064260.V258521.R01.S.doc Version 5.0 Page 26 - 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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