Inspection on 24/01/06 for St Michael`s Mount

This inspection was carried out on 24th January 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 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 12/09/07

St Michael`s Mount 21/07/06

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 John McCabe Unannounced Inspection 24th January 2006 02:00 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 St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 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.V272886.R01.S.doc Version 5.1 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.V272886.R01.S.doc Version 5.1 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 7th September 2004 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 gradens. 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. St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 24/01/06 at 1400 hours with the registered manager of the home. The inspection took place over four hours. Documents for residents and staff were reviewed, and a full inspection of the building took place, which included bedrooms, laundry, kitchen and the garden areas. A number of residents, staff and a community nurse were spoken to during the inspection period, to get their views on the conduct of the home. What the service does well: What has improved since the last inspection? What they could do better: Care staff has been working in the home for six weeks without an enhanced CRB/POVA check or a POVA First clearance. The registered manager needs to ensure that the necessary recruitment checks are complete and evidence to confirm this is maintained for inspection purposes. The gardens of the home are overgrown, neglected, and littered. The patio stones are uneven, dirty, with weeds growing in between slabs. The area is an eyesore and dangerous both for residents and staff. St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 Page 6 The home must employ more domestic staff to keep the home clean and tidy and free from smells. 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. St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 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.V272886.R01.S.doc Version 5.1 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): 1,2,3,4,5. The Home’s Statement of Purpose is up to date and ensures that the home stays within the category of resident agreed with the commission, and prospective residents have some knowledge of the home before they decide to move in on a permanent basis. The residents’ pre-admission assessment documentation is robust and comprehensive; but must be completed before any resident is admitted to the home to ensure that the skill mix of the workforce in the home can meet the residents identified care needs. EVIDENCE: The Home’s Statement of Purpose is up to date and ensures that the home stays within the category of resident agreed with the commission, and prospective residents have some knowledge of the home before they decide to move in on a permanent basis. The home’s senior nurses undertake a nursing pre admission assessment on residents before they are admitted to the home, to ensure care needs are St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 Page 9 Identified and can be met. Other health care professionals known to the resident are also involved in the assessment. Care staffs in the home do undertake specialist care training, which includes stroke, dementia care, diabetes, and challenging behaviours. The training is ongoing, to ensure that the assessed and changing care needs of the residents are met. St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Residents’ individual health, personal and social care needs are clearly recorded. This provides care staff with the information they need to meet the residents care needs. EVIDENCE: All residents in the home have an individual care plan, which is formulated on admission to the home and is reviewed by the senior nurses on a monthly basis. Residents and family also contribute the formulation of the plan. Health records are documented daily for each resident, this includes any critical incidences plus any visits from GPs, specialist nurses etc. No resident in the home self medicates as the nurses in the home administer all medications for residents. The protocols for the receipt, storage, disposal, and documentation of medications in the home are in accordance with the National Minimum Standards (NMS). The senior nurses in the home are reviewing how residents. unwanted medications are removed form the home by the contracted clinical waste company. St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 Page 11 Most of the care staff has undertaken training on tissue viability. The Primary Care Trust (PCT) tissue viability nurse will visit the home at any time if needs arise. Photographic and skin mapping evidence for pressure sores is recorded in the resident’s personal file. This allows for the appropriate monitoring and treatment. All residents in the home can access their NHS entitlements, which includes dentistry, opticians and chiropody services. On the day of the unannounced inspection, residents told the inspector that staffs in the home were always courteous, respectful, and that they maintained residents’ privacy and dignity when assisting with personal care. St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Residents have choice and flexibility how they spend their day in the home, and can pursue leisure and educational activities according to their choice and preferences. This allows independence and individuality for each resident. Residents receive a balanced diet offering variety, which reflects the residents’ preferences. EVIDENCE: Residents in the home are asked on admission, about their lifestyle, choice of foods, and choices and preferences of the social activities they would like to participate in. On admission to the home the resident with help from a family member completes a Social Assessment questionnaire, which is a “Work life History” of the resident, and includes schooling, work, hobbies, food likes and dislikes etc. This information is used to facilitate organised activities for the resident. The home does not employ an activities coordinator, carers undertake to organise the social activities. When residents participate in social activities, it is recorded in their daily health record sheet, how they participated in the activity. This is to ensure that there St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 Page 13 is recorded evidence of how the resident coped /responded in the activity, and to their mood, emotions, physical dexterity etc. The recordings of the resident activities helps to complete a “full picture” of the residents progress, or even identify developing care needs. Visitors are allowed in the home at any reasonable time of day and residents may entertain their visitors in the communal lounges, or in their own bedroom. Residents told the inspector that they enjoyed the variety of food in the home. Some of the residents prefer to take their meals in their own room rather than go to the dining room. Menus for each day are printed in large print in the resident’s dining room. Therapeutic diets can be catered for in the home for residents with a medical condition. St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18. The home has a satisfactory complaints system with evidence that residents feel their views are being listened to and acted upon. The home’s policy and training programmes for POVA, and Whistle Blowing, ensure that the homes residents are protected from any abuse. EVIDENCE: Since the last inspection there have been no internal complaints, or complaints to the CSCI. It was positive to note that resident’s legal rights to exercise the right vote is encouraged and supported with many of the residents using their postal vote in the last General Election. The care home has up to date information on the Protection of Vulnerable Adults (POVA), and there was evidence that many of the staff had undertaken training on POVA protocols, and the Whistle Blowing Policy. St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26. More effort is needed to improve the cleaning of the interior of the home to ensure the health and safety of the residents. The rear gardens of the home are an eyesore; they are neglected, overgrown, littered; and would be potentially dangerous for residents, staff and visitors to enter. EVIDENCE: The home was not as clean and tidy as it could be as there was only one domestic on duty. This is a large home with single bedrooms and a number of corridors many of which had not been vacuumed on the day. The task for one person to keep the environment clean is a sizable one. The registered person is currently advertising for staff, as she was in October 05. Since the last inspection the rear gardens of the home have deteriorated even further; no attempt has been made by the registered person to improve the area. St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 Page 16 The garden is overgrown with grass, trees; bushes have not been tended for at least a year. Patio slabs are uneven, and are dangerous to walk, presenting a risk for potential slipping due to the build up of slime and moss. Residents, staff and visitors are not allowed into to the garden space because of the potential dangers. What could be a very pleasant view with a water fountain for the residents is obliterated because due to the apparent neglect. All of the bedrooms in the home are single occupancy, and most of the residents have personalised their bedrooms with pictures and memorabilia. The home’s washing machines in the laundry have had an Eco system fitted to them (OTEX). This enables soiled washing to be cleaned at lower temperature, using less electricity, soap and water. The washing is ionised and aerated to allow widening of the cloth fibres so soaps can penetrate the fibres and kill more bacteria, including MRSA, and Hepatitis B and C. Monitoring of the room is essential in case of an Ozone leak from the system. The home’s updated infection control policy includes the prevention and spread of Methicillin Resistant Staphylococcus Aureus and Hepatitis B and C. St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29. The standard of vetting and recruitment practices has deteriorated with the appropriate checks not being carried out on all new staff. This places the residents at potential risk. EVIDENCE: There is always a first level nurse on duty that is assisted by care staff and ancillary staff. A least one-member of staff has been working in the home for some weeks without an up to date enhanced CRB/POVA certificate. This was a legal requirement in the last inspection report, and yet the manager still does not adhere to the NMS and regulations regarding recruitment of staff The inspector told the manager that it is a significant failure to comply with regulations, should staff be employed without the required vetting. Staff must not commence employment prior to all of the necessary checks being undertaken. This includes CRB checks at an enhanced level or a POVA first check. The inspector evidenced the Personal Identification Numbers (PINS) of all the registered nurses in the home, which was documented on Nursing Midwifery Council (NMC) stationary. St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 Page 18 Mandatory and specialist training for all staff is ongoing in the home; this is evidenced in the personal files of the staff. The home has two overseas nurses undertaking an Adaptation Course to enable them to register as First Level nurses with NMC. St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,26,37,38. Staff morale is high in the care home, resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life, plus the turnover of care staff is low. However, the registered manager must exercise appropriate control over the checking and vetting of all staff especially in respect of the recruitment, to ensure the welfare of residents. EVIDENCE: An experienced first level nurse manages the home; currently the manager has not registered on an NVQ Level 4 care programme. All staff in the home have documented supervision six times per year, this ensures that all staff have the opportunity to discuss with the manager, and other senior nurses, any issues, which can effect or improve the care for the St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 Page 20 residents. Documented supervision of all staff gives the staff and manager’s opportunities to discuss their own/or identified training needs. Where possible residents look after their own financial affairs as the home doesn’t hold any bank accounts for individual residents. The homes certificates of insurance and worthiness for machines, gas, electricity, fire equipments, lift, hoists were in date and valid. The Employer’s Liability Insurance certificate is displayed in the main hall of the home and is valid and in date. Personal files of both staff and residents are kept secured in accordance with the Data Protection Act 1998, thus maintaining confidentiality. St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 18 3 1 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 3 3 3 3 3 St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 Page 22 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 OP29 Regulation 19 Requirement The registered person must ensure that staffs are not employed in the home without an up to date CRB/POVA, or a POVA First Certificate. Previous Timescale of the 31/10/05 Not Met. 2 OP19 23 The registered person must ensure that the paving area at rear of the garden is cleaned, and weeds removed to ensure the safety of staff and residents. Previous Timescale of the 31/10/05 Not Met. 3 OP26 23 The registered manager must ensure that there is sufficient domestic staff on duty to keep the home clean and tidy. Previous Timescale of the 31/10/05 Not Met. 28/02/06 28/02/06 Timescale for action 28/02/06 St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 Page 23 4 OP31 19 The registered person must ensure that the registered manager of the home complies with the NMS and the Care Standard Act 2000.This refers to employing staff in the home without the appropriate recruitment checks. 28/02/06 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 St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 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. Extracts may not be used or reproduced without the express permission of CSCI St Michael`s Mount DS0000025184.V272886.R01.S.doc Version 5.1 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. 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