Cummal Mooar Residential Home, Ramsey

Summary

A request was made for financial records, inspection reports, closure meeting notes, and land sale inquiries regarding Cummal Mooar Residential Home. The Department of Health and Social Care provided an unannounced inspection report from 2018 but indicated that not all requested information was held.

Key Facts

• The request covered income/expenditure for 5 years, inspection reports, closure meeting notes, and land purchase offers.
• The authority responded that some information was sent but not all was held.
• An unannounced inspection report dated September and October 2018 was included in the response.
• The inspection found the service 'Not met' regarding mandatory staff training and 'Partially Met' for policy reviews.
• The facility was identified as the Cummal Mooar Resource Centre with 40 individuals attending at the time of inspection.

Data Disclosed

• 2023-07-28
• 2024-05-13
• 18/09/2018
• 24/10/2018
• 15 & 20 September 2018
• 40
• (01624) 814167
• IM8 1EL
• Regulation of Care Act 2013
• Section 37
• Standard 1.3
• Standard 3.13
• Standard 4.10
• Standard 6.3
• Standard 6.8
• Standard 6.9 & 6.16
• Standard 7.3

Original Request

Copies of Income and expenditure for this building over the last 5 years. Inspection reports on the building. Copies of all meeting notes discussing and including the decision to give notice to close the facility. Copies of any requests, offers or approaches by outside parties to purchase, develop or lease the land.

Data Tables (56)

Full Response Text

Department of Health and Social Care Rheynn Slaynt as Kiarail y Theay

Regulation of Care Act 2013

Adult Care Homes

Cummal Mooar

Unannounced Inspection

18/09/2018 24/10/2018

Registration and Inspection Unit,
Ground Floor, St George’s Court, Hill Street, Douglas, Isle of Man, IM1 1EF.

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Contents

Completing and returning your report

To complete your report form, enter text by clicking on the box, use the tab key to move to the next box.

1. Provider’s action plan and response a. Add details of your actions to complete the requirements/recommendations (if applicable)
   b. Confirm you have read and agree/disagree the contents of the report by clicking on the appropriate box c. Sign (type name when returning electronically) and date

2. Return your report to randi@gov.im within 4 weeks

3. Do not use any other method e.g. links to Cloud or other file sharing services

Part 1: Service information

Part 2: Descriptors of performance against Standards

Part 3: Inspection Information

Part 4 : Inspection Outcomes and Evidence and Requirements

Part 5: Provider’s action plan and response

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Part 1 - Service Information for non-Registered Service

Name of Service: Cummal Mooar Resource Centre Tel No: (01624) 814167

Address:
Queens Promenade Ramsey Isle of Man IM8 1EL

Email Address:
Claire.Cummins@gov.im

Name of Manager:
Claire Cummins

Date of any additional regulatory action in the last inspection year (i.e. improvement measures or additional monitoring):
None

Date of previous inspection:
15 & 20 September 2018

Number of individuals using or attending the service at the time of the inspection:
40

Person in charge at the time of the inspection:
Claire Cummins

Name of Inspector(s):
Mandy Quirk & Egle Leadley

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Part 2 - Descriptors of Performance against Standards

Inspection reports will describe how a service has performed in each of the standards inspected. Compliance statements by inspectors will follow the framework as set out below.

Compliant Arrangements for compliance were demonstrated during the inspection. There are appropriate systems in place for regular monitoring, review and any necessary revisions to be undertaken. In most situations this will result in an area of good practice being identified and comment being made.

Recommendations based on best practice, relevant research or recognised sources may be made by the inspector. They promote current good practice and when adopted by the registered person will serve to enhance quality and service delivery.

Substantially compliant Arrangements for compliance were demonstrated during the inspection yet some criteria were not yet in place. In most situations this will result in a requirement being made.

Partially compliant Compliance could not be demonstrated by the date of the inspection. Appropriate systems for regular monitoring, review and revision were not yet in place. However, the service could demonstrate acknowledgement of this and a convincing plan for full compliance. In most situations this will result in requirements being made.

Non-compliant Compliance could not be demonstrated by the date of the inspection. This will result in a requirement being made.

Not assessed Assessment could not be carried out during the inspection due to certain factors not being available.

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Part 3 - Inspection information

The purpose of this inspection is to check the service against the service specific minimum standards – Section 37 of The Regulation of Care Act 2013 and The Regulation of Care (Care Services) Regulations 2013.

Inspections are generally themed, concentrating on specific areas on a rotational basis and for most services are unannounced.

The inspector is looking to ensure that the service is well led, effective, safe and compassionate.

No Standard Requirements/recommendations from previous inspection Met/not met 1 1.3 Pre admission assessment must consider compatibility Met 2 3.13 PEEPS must be in place for all residents Met 3 4.10 Fire alarm checks must be carried out weekly Met 4 6.3 Staff files must contain all pre employment checks Substantially Met
5 6.8 All staff must have a minimum of four supervisions per year Met
6 6.9 & 6.16 All staff must be up to date with mandatory training and refreshers. Not met
7 7.3 Policies and procedures must be reviewed and updated within identified timescales. Partially Met

Part 4 - Inspection Outcomes, Evidence and Requirements

Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 2 - Daily Living People are supported to set and carry out their activities and routines in suitable surroundings. The environment is conducive to people’s well-being and safety. People live in a home that is safe, warm clean and comfortable. People have access to the aids, equipment and facilities they need. 2.10, 2.11, 2.12, 2.13, 2.14, 2.15

Our Decision: Compliant

Reasons for our decision: The inspectors had an opportunity to examine a number of randomly selected resident records. The home used an electronic system to record need assessments, care plans, risk assessments and progress notes. All care plans seen contained records of resident daily routine preferences such as getting up and going to bed, bathing and meals.

The menu was examined by the inspectors. Choices were available for each meal. The menu contained varied and nutritious meals. Residents were regularly asked for feedback in regards to quality of food. The file containing various comments about food was seen by the inspector. All comments were responded to and signed off by the chef. The menu was also standing agenda

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item in all resident meetings. Eating and drinking assessments were completed for every resident.
Drinks and snacks were readily available at the home.

Opportunities for appropriate activities were provided at the home. An activity log evidenced a wide range of activities, including: paws for therapy, chair based exercise, card making, manicure, bingo, reminiscing, quizzes, singing for brain, various outings, social nights etc.

Evidence Source:

Observation  Records  Feedback  Discussion

Requirements and Recommendations None

Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 3 – Daily Support People are confident that the staff will support them to maintain their health and to support their social and welfare requirements.

Our Decision: Substantially compliant

Reasons for our decision: The inspectors had an opportunity to examine number of randomly selected care plans. All care plans seen were recently reviewed and the next review date was identified. Progress notes evidenced residents and/or their representatives’ involvement in care planning and reviews.

Nutritional needs were assessed using an eating and drinking assessment tool. Where the need was identified, it was included in the care plan.

Known medical conditions were noted in the care records and provided the instructions of how to support and maintain them. However one of the care plans examined did not included information in regards to all recorded medical conditions.

Contact details of identified health care professionals were available in the file. The visits to/from them were appropriately recorded.

Social, cultural and emotional wellbeing has been factored into the care records seen by the inspectors.
Communication needs were assessed and recorded. Identified needs were included in the care plans.

Where challenging behaviours were identified detailed care plans were in place. Staff members have access to training in Dementia Capable Care which focuses on the use of de-escalation techniques for service users with dementia. However not all staff were up to date with training (addressed under standard 6.9).

Residents’ likes and dislikes in regards to leisure interests and hobbies and daily routines had also been documented in the care records seen.

Specialist furniture and equipment required was identified in the care records.

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Personal Emergency Evacuation Plans (PEEP) were in place for all residents. A number of randomly selected PEEP’s were examined by the inspectors, all of them were found to be in date with the next review date identified.

All care records scrutinised by the inspectors contained records of people’s wishes as they approach the end of their life.

Where the person expressed the wish not to be resuscitated, the appropriate form was completed and signed by the doctor. However the inspectors noted that one DNACPR form was overdue the review and several other forms were not fully completed and did not have the next review date identified.

Where individual risks were identified relevant risk assessments were in place. All risk assessments seen were in date and reviewed regularly.

There were clear arrangements for handling service user’ finances. Records showed that any monies held or managed by the home were subject to an annual compliance inspection. Detailed records and checks were maintained by the service.

The records showed that the medication lists were reviewed annually by a GP.

Medication was stored in locked cabinets within a locked room with restricted access.

Medication records for all residents were examined and found to be in good order. The majority of the medication records, with an exception of few, had photographs on front sheets to minimise any potential for administration errors. There were a small number of gaps in staff signatures identified on Medication Administration Record (MAR) sheets. The gaps noted by the inspectors were not identified in the internal audit of medication systems and processes (22/08/18) or mini medication audit.

Medication was found to be dispensed and administered, in line with assessed needs. Records showed that staff competence to administer medication was assessed annually, however one member of staff was overdue an assessment. Following the inspection the manager confirmed that an overdue assessment was completed.

Training records showed that the majority of staff were up to date with basic medication and 1st aid training. However few members of staff were due 1st aid training, it was noted that the training sessions were booked and one member of staff was overdue medication refresher training.

First aid boxes were found in various locations around the premises.

Evidence Source:

Observation  Records  Feedback  Discussion 

Requirements and Recommendations Four requirements made

Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 - Environmental and Personal Safety and Comfort Systems, checks, policies, procedures and staff training ensure that people’s dignity, well-being

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and safety is promoted and protected. 4.1, 4.2, 4.3, 4.4, 4.8, 4.9, 4.10, 4.16, 4.17

Our Decision: Substantially compliant

Reasons for our decision: The service had a range of policies and procedures to safeguard people from poor practice and abuse. The Isle of Man Government Inter Agency Adult protection Policy and Procedure 2016- 2018, guidance on how to raise an adult protection alert and confidential reporting (whistleblowing) policy were available to staff. The confidential reporting policy was dated 2016 and did not have a review date identified (addressed under standard 7.3). The training records showed that all staff were up to date with adult protection training.

The inspectors had an opportunity to examine an environmental risk assessments file. The file contained wide range of environmental risk assessments, all of which were recently reviewed with the next review date identified. Home had a range of health and safety policies and procedures, however some of them were past the review date identified (addressed under standard 7.3). The training matrix showed number of gaps in health and safety training, it was noted by the manager that this was due to lack of training availability.

The home had a complaints policy and procedure in place. The procedure was displayed at the service and included all information required. Complaints and compliments records were examined by the inspectors. Four complaints were recorded since the last inspection. All complaints were appropriately recorded, dated and signed.

Fire safety file contained:  Evidence of regular fire drills;  Evidence of weekly fire alarm tests;  An annual fire detection and alarm system inspection on 23/11/17;  Evidence of monthly fire extinguisher and fire blanket checks;  Evidence of monthly emergency lights checks;  An annual firefighting equipment service dated 25/07/18;  An up to date fire safety risk assessment;  Evidence of quarterly fire inspection checklists;  Evidence of an annual fire safety audit;  Evidence of 6 monthly fire door maintenance checklists;

Electrical Installation condition report dated 05/05/18 was available for inspection. It was noted that the report covered 20% of the electrical circuits.

Portable Electrical Appliance Testing was carried out recently and evidence of the testing was available for inspection.

Water analysis report dated 24/04/18 was available for inspection and risk assessment was in place. Hot water thermostatic mixing valves maintenance checks were last recorded on 17&19/04/18. A number of wash hand basin water temperatures recorded exceeded the recommended limit.

A Gas safety inspection was carried out on 17/04/18.

Up to date employer liability insurance was in place and appropriately displayed.

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Evidence Source:

Observation  Records  Feedback

Discussion 

Requirements and Recommendations Two requirements made

Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 - Staffing
Staff are recruited following a rigorous and robust recruitment programme. There are sufficient numbers of trained competent staff (including ancillary staff) to meet the needs of the people at the home. There are robust policies in place to ensure effective supervision and continuous professional development. 6.3, 6.20, 6.21, 6.22, 6.23

Our Decision: Substantially compliant

Reasons for our decision: The Inspectors had an opportunity to exami

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