Inspection on 12/09/07 for St Michael`s Mount

This inspection was carried out on 12th September 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Michael`s Mount 21/07/06

St Michael`s Mount 24/01/06

St Michael`s Mount 12/10/05

St Michael`s Mount 07/09/04

St Michael`s Mount 07/06/04

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 St Michael`s Mount Woolton Road Liverpool Merseyside L25 7UW Lead Inspector Jeanette Fielding Key Unannounced Inspection 12th September 2007 10:30 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 St Michael`s Mount DS0000025184.V335448.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. St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Michael`s Mount Address Woolton Road Liverpool Merseyside L25 7UW 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) 0151 427 9419 Mr Michael Hanlon Mr James Mutch Elma Draper Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 45 Nursing Care and 45 Personal Care in the overall number of 45 Date of last inspection 21st July 2006 Brief Description of the Service: St Michaels Mount is one of two adjacent care homes situated in a quiet residential area of South Liverpool. Both homes are owned by a private company. St Michaels Mount is registered both for residential and nursing care. Trees and grassed areas surround the home which gives a sense of privacy, plus the home has its own gardens. There is a car park to the side of the home. The building is purpose built and consists of two floors. The upper floor is served by passenger lifts and stairs. Accommodation for residents is provided in single rooms many of which have a toilet and hand wash basin. The home is centrally heated. There is a large central lounge, a separate dining room with conservatory. The home is close to public transport, rail and bus and is near to the M62 and M57 motorways. The fees for the home range from £290.50 to £423 per week which includes a £17.50 top up above local authority rates. St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted in one day over a period of six and a half hours. This was the key unannounced inspection and was carried out as part of the regulatory process. As part of the inspection process, all areas of the home were viewed including many of the service users bedrooms. Assessments and care plans were inspected together with staff records and certification to ensure that health and safety legislation was complied with. Discussion took place with the registered manager, nurses, care staff, service users and visitors to the home. Questionnaires were issued to service users to obtain further information. What the service does well: What has improved since the last inspection? What they could do better: Investment is required to improve the standard of some of the furnishings and décor within the home. Some health and safety issues require to be addressed including work to improve the floor and the storage facilities within the kitchen. St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. St Michael`s Mount DS0000025184.V335448.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 St Michael`s Mount DS0000025184.V335448.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comprehensive assessment is undertaken on all prospective service users to identify their needs and to ensure that those needs can be met. EVIDENCE: The registered manager is currently working to update the Statement of Purpose and the Service User Guide as she has identified that parts of the documents are not as clear as she would wish. A copy of the documents should be forwarded to CSCI on completion of the update. Detailed pre- admission assessments are undertaken on all prospective service users prior to their admission to the home. The assessments are undertaken by the manager or one of the senior sisters and information is gathered from the service user, their family, the social worker, the long term care team and St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 Page 9 other multi disciplinary teams as necessary. Information is gathered regarding the service users medical, care and social needs and individual preferences are identified. Sufficient information is gathered to ensure that the home can meet all of the service users individual needs. The assessment provides sufficient information for a plan of care to be prepared. More detailed information is recorded following admission to the home as the service users’ needs change. Prospective service users and their relatives are encouraged to visit the home prior to admission to view the rooms available and to meet other service users and staff. The home does not offer Intermediate Care. St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed care plans are prepared for each service user and are reviewed and updated on a regular basis to ensure that service users are provided with the appropriate level of care. EVIDENCE: Care plans are prepared for each individual service user. These are prepared, initially, from the information gathered in the pre-admission assessment. All care plans are reviewed on a monthly basis, and more frequently as necessary, to ensure that service users changing needs are identified and to ensure that staff are given full details about the level of care to be provided. Care plans inspected were extremely detailed and included individual plans relating to personal care, nursing care, nutrition, social preferences and all St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 Page 11 other aspects of care. Detailed information is held regarding wounds which are photographed and mapped to allow for monitoring and treatment. Risk assessments are undertaken and risk management plans set in place to remove or reduce any potential risk to the service user. Risk assessments were found to be informative to provide staff with full details of how to ensure the safety of the service users. Care files were extremely organised and information was easily accessed. The daily reports completed by staff provide evidence that service users health care needs are fully met. The home has comprehensive and detailed policies and procedures for the administration of medications. Medications were found to be dealt with by the staff in accordance with the home’s policy and procedure. All records relating to medications were completed accurately and storage areas were clean and organised. Handwritten entries on Medication Administration Record sheets are signed by two members of staff to ensure accuracy of the entries. Regular audits of medications are undertaken to ensure that the home’s safety standards are maintained. Training has been given to care staff on medications and this is evidenced in their files. Personal care is given to service users in their bedroom or in the bathroom as necessary. Staff were observed to knock on bedroom doors and to wait for an answer prior to entering. One relative said ‘The staff are wonderful. They do everything for mum. They really care and are so kind’. St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A high number of activities are available to service users to provide them with social stimulation. EVIDENCE: On admission to the home, staff work with service users and their relatives to complete a Social Assessment questionnaire. This is to identify the service user’s past history and to gather information regarding their individual preferences with regard to daily and weekly routines, food likes and dislikes and the different social activities that take place within the home. This information is used to facilitate organised activities which are provided by the staff team. A high number of activities are provided for service users which includes parties, garden fete and fundraising. Board games and quizzes are enjoyed by the service users. The home’s mini-bus was stolen and at present, trips out are restricted. Service users spoken to said that they missed the trips out and the opportunity to visit local shops. Planned facilities include a memorial garden, a raised garden area where service users can become St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 Page 13 involved with the nurturing of plants and a barbeque. Clothing parties are held and a bonfire party has been arranged for November. Two service users recently celebrated their 100th birthday and parties were held for these. The home does not employ and activities co-ordinator and consideration should be given to the provision of a person to provide stimulation for the service users and to co-ordinate activities and entertainment. Visitors are welcome to visit the home at any time and service users may meet with their visitors in one of the communal areas or in the privacy of their bedroom. Service users are encouraged to take their meals in the dining room to promote social interaction, however, they may take their meals in their bedroom if they wish. The dining tables were attractively laid with pretty table cloths, place mats, condiments, glasses and napkins. It was noted however, that the table cloths in the linen room were worn and frayed. The use of the alternative table cloths would detract from the overall ambience within the dining room and remove the high standard that the staff strive to achieve. A choice of meal is available to all service users and the chef has details of special diets and individual preferences. The menus provide evidence that a nutritious and balanced diet is offered. A cooked breakfast is available each day and the main meal is served at lunchtime. A lighter meal is served in the evening and offers a choice of a hot meal or soup and sandwiches. Supper is served in the evening and snacks are provided mid morning and afternoon. The meals are prepared in the main kitchen. The kitchen is clean and organised but attention is required to be given to the flooring which is lifting in parts and has been temporarily repaired by the use of adhesive tape. This has the potential for presenting as a tripping hazard and should replaced or appropriately repaired as a matter of priority. Service users spoken to said that the meals in the home were really good and that they enjoyed them. One service user said that she liked the ‘home cooked type of meals’ that are served. St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a robust complaints procedure to protect service users. EVIDENCE: The home has a comprehensive complaints procedure and information regarding this, and how to make a complaint, is displayed in the hallway of the home and also detailed in the Statement of Purpose. Service users said that they knew who they could complain to but were happy with the service and found no reason to complain. Three complaints have been made against the service in the last three months, one of which is currently under investigation. The other two complaints were actioned appropriately and within the required time frame. The records held on the staff files show that training on abuse has been given. Discussion with staff demonstrated that they were aware of the different types of abuse and of the action that would be taken if it were suspected. All staff have had appropriate checks made on them to ensure that service users are protected within the home. St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment at St Michaels is homely but would benefit from a programme of refurbishment. EVIDENCE: St Michaels Mount is a purpose built care home which is registered to accommodate 45 elderly persons for nursing or personal care. All service users are accommodated in single bedrooms, some having en-suite facilities. The home is maintained to an adequate condition and the programme of redecorations continues but further investment is required to improve the standards within the home. One comment received in the questionnaire issued to service users referred to service users being informed that the premises St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 Page 16 were due for redecoration but there was no evidence of this work being commenced. The exterior of the building shows that some windows have been replaced but the lounge window on the exterior requires to be repainted as all paint has flaked off, exposing the bare wood. A pleasant conservatory is used as the dining room. The blinds in the conservatory are faded and detract from the overall ambience. Some of the dining chairs are showing signs of wear. The main lounge has recently been redecorated but some of the armchairs are worn and faded. This area would be improved by the replacement of the armchairs. It is evident that every effort has been made to personalise service users bedrooms with pictures, photographs and items of memorabilia. The curtain rails in many of the bedrooms require to be replaced due to their poor condition. The carpets in three bedrooms have become worn and stained and would benefit from replacement. Bedroom number 52 has previously suffered water damage in one corner on an exterior wall. It is evident that action has been taken in respect of this but no repairs have yet been made to the damaged décor. The redecoration of one bedroom had commenced some months ago and has not yet been completed. This room is occupied by a service user and requires to be addressed as a matter of some urgency. The kitchen floor requires attention to remove the potential tripping hazard. Some of the shelving in the kitchen store room is damaged and unsafe and requires to be repaired or replaced as necessary. Cold water pipes extend across the kitchen ceiling and condensation builds up on these. The condensation subsequently drips on to the floor which may present as a hazard. Appropriate measures should be taken to prevent accidents as a result of this. The home provides three bathrooms and two showers. Many of the service users said that they enjoyed showers but that they sometimes had to wait as they were in use. The home provides four sluices. Consideration could be given to changing the use of the larger sluice into a shower room to improve the facilities for service users. St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 Page 17 The home provides a range of equipment to assist service users who have mobility problems and all staff have been given training to use the equipment and to move service users safely. Lined stocks in the storage areas and laundry showed that the supply of bedding is low. Sufficient bedding is to be provided. All areas of the home were found to be clean and there were no unpleasant odours. Work is currently taking place to improve the garden to provide service users with a pleasant area to use in preparation for next summer. The garden area currently provides a decked area and a large patio with seating. A ramp is provided to give access to the patio area to wheelchair users or those who have mobility difficulties. One response to the questionnaire issued to service users commented on the poor condition of the garden. St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a robust recruitment policy and procedure to ensure that service users are protected. EVIDENCE: The staff rota provides evidence that sufficient staff are employed and deployed to meet the needs of the service users. During the morning and early afternoon, two qualified nurses are supported by eight care assistants. During the late afternoon and evening, two qualified nurses are supported by six care assistants. At night, one qualified nurse is supported by three care assistants. A high level of training has been provided for staff with 71 of the care staff holding NVQ qualifications. Recent training includes first aid, moving and handling, health and safety, basic food hygiene, the care of the elderly, skin care, equality and diversity and anatomy. Qualified nurses are given training to enable them to maintain their registration and recent courses include venepuncture, tissue viability, dementia care, mentorship and palliative care. Detailed records are held on staff files of all training undertaken. St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 Page 19 The home has a robust recruitment procedure and the files inspected provided evidence that this procedure has been followed. Prospective staff are required to complete an application form prior to interview. Two references are taken and checks are made with the Criminal Records Bureau and Protection of Vulnerable Adults registers. Gaps in employment history are checked and evidence of training and qualifications are required to be produced. Staff spoken to during the inspection confirmed that a high level of training was offered and that they were supported by the home’s manager. All staff spoken to were able to demonstrate that they were aware of the adult protection procedure and of the action to be taken in the event of abuse being suspected. Appraisals are undertaken on all staff every two months to identify training needs and to ensure that the staff are competent and confident in their work. St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is supported well by the senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: The manager of the home is a qualified nurse who has considerable experience in the management of care for elderly people. She holds an NVQ 4 in management. She is supported by senior nurses who are experienced in providing care for elderly people. St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 Page 21 The records held in the home are extremely detailed and organised and provide evidence that the home is run in the best interest of the service users. Regular service user and relatives meetings are held and minutes are held of issues discussed. Attendance at these meetings is quite low but the manager explained that she spoke with relatives and service users on a one to one basis to give information and discuss care issues. Where possible, service users look after their own financial affairs. The home has a non-interest bearing bank account for service users money which they use if they wish. Information regarding this is detailed in the statement of purpose. All safety certificates inspected were well maintained and up to date. Evidence is held on the tests made on fire equipment, hot water and moving and handling equipment. The Employers Liability Insurance certificate is displayed in the main hall of the home and is valid and in date. Personal files of both staff and service users are kept secured in accordance with the Data Protection Act 1998, thus maintaining confidentiality. St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 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 2 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 3 X 3 X 3 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 4 X 3 X 3 X 3 3 St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP19 Regulation 23(2) Requirement The Registered Person must ensure that the flooring in the kitchen is replaced or adequately repaired. The Registered Person must ensure that the home is maintained in a good condition. The Registered Person must ensure that the worn carpets are replaced. Timescale for action 31/10/07 2. 3. OP19 OP19 23(2) 23(2) 31/10/07 31/03/08 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 OP1 Good Practice Recommendations A copy of the Statement of Purpose and Service User Guide should be forwarded to CSCI on completion of the review and update. Consideration should be given to employing an activities co-ordinator. Additional bedding should be provided. 2. 3. OP12 OP19 St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Merseyside Area Office 2nd Floor, South Wing Burlington House Crosby Road North Waterloo L22 0LG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 St Michael`s Mount DS0000025184.V335448.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!