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Inspection on 06/11/07 for Northwood Nursing Home

Also see our care home review for Northwood Nursing Home for more information

This is the latest available inspection report for this service, carried out on 6th November 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

People were given clear information about services offered at Northwood. This helped them to decide whether the place was suitable for them and whether their needs could be met. People were only admitted to Northwood after their needs had been assessed to make sure that they could be properly cared for at the home. Everyone living at the home had a care plan to tell staff what care they needed and how they liked to be helped. People said that staff looked after their health very well. A relative said they had no worries about their mother`s health care. The principles of privacy, dignity and respect were put into practice. People living at the home said that staff were polite. Several talked about staff giving them privacy when in their rooms. The programme of activities was well thought out to appeal to a wide range of interests and tastes. A number of people living at the home commented that they enjoyed the different activities such as the men`s group and film shows. There was an open visiting policy, which meant that people could see their relatives at any time. Visitors said they were made to feel welcome. People said they were given choices in many aspects of their day. One person said there were no rules about anything. People living at the home were offered a varied and nutritious diet. The chef was runner up in a national competition to award people catering for the care services. People were complimentary about the meals. One person said, "The food is too good, I`ve put on about 5 pounds." A relative wrote that one of the strengths of the home was, "home cooking with fresh ingredients." There was a clear complaints procedure and people living at the home said they could speak to senior staff if they were unhappy about anything. Relatives who returned surveys indicated that the management acted upon any concerns they raised. People who talked to the inspector and those who returned surveys were positive about the staff and management team. One person said, "The staff are very good with us." Another described the management team as brilliant. Over half of the care staff held a nationally recognised qualification in care.

What has improved since the last inspection?

Further improvements had been made to the environment. The owners had a list of areas that they were working on to make the home even more comfortable for people living there. More staff had received training in topics that helped to protect people`s health and safety, for example moving and handling and food hygiene. Staff also went on courses to improve their knowledge when caring for people with certain illnesses such as diabetes.

What the care home could do better:

The staff generally managed medication safely but some improvements were needed to reduce the risk of errors and to make sure that the manager had enough information to carry out thorough checks. The registered person must ensure that they carry out thorough background checks on new staff before they start work in the home. This is to ensure, asfar as possible, that the staff are fit to work with people who may be vulnerable to abuse.

CARE HOMES FOR OLDER PEOPLE Northwood Nursing Home 206 Preston New Road Blackburn Lancashire BB2 6PN Lead Inspector Jane Craig Unannounced Inspection 6th November 2007 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 Northwood Nursing Home DS0000022475.V350281.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. Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Northwood Nursing Home Address 206 Preston New Road Blackburn Lancashire BB2 6PN 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) 01254 57208 01254 878728 Mr Brian J O`Neill Mrs Eileen O`Neill vacant post Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (27), Physical disability (24) of places Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Within the overall total of 28, a maximum of 23 service users requiring nursing care who fall into the category of either PD or OP Within the overall total of 28, a maximum of 27 service users requiring personal care in the category of OP Within the overall total of 28, 1 named service user requiring personal care in the category of PD 25th October 2006 Date of last inspection Brief Description of the Service: Northwood provides long and short-term care for a maximum of 28 residents who are elderly and have physical need for which they need nursing care. The registered persons are Mr and Mrs O’Neill. Mrs O’Neill takes responsibility for managing the home on a day-to-day basis. The home is a converted and extended Victorian property, which has retained its style and character. It is located in a residential area within close proximity of all local amenities (shops, churches, bus route and public houses) and less than a mile from the centre of Blackburn. Bedrooms at the home are a mix of single and shared rooms, some of which have en-suite facilities. There are a number of lounge and dining areas located on the ground floor. A passenger lift serves both floors. Residents have access to the large garden and patio area. Car parking space is located to the front of the house. Information about Northwood is sent out to prospective residents when they enquire about admission. The latest CSCI inspection report was on display in the manager’s office and is available to residents on request. At 6th November 2007 the fees ranged between £372.00 and £497.50 per week. There were additional charges for newspapers and some hairdressing. Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Northwood on the 6th November 2007. At the time of the visit there were 20 people living at the home. The inspector met with some of them and asked about their views and experiences of living at Northwood. Some of their comments are included in this report. Three people living at the home were case tracked. This meant that the inspector looked at their care plans and other records and talked to staff about their care needs. As part of the key inspection a number of surveys were sent out to people living at the home, their relatives, staff working at Northwood and visiting health professionals. Comments received on the surveys have been taken into account when compiling the report. During the visit discussions were held with one of the owners, the general manager, four members of the staff team and visitors to the home. The inspector looked round the home and viewed a number of documents and records. This report also includes information from the Annual Quality Assurance Assessment (AQAA), which is a self-assessment that the provider has to fill in and send to the Commission every year. What the service does well: People were given clear information about services offered at Northwood. This helped them to decide whether the place was suitable for them and whether their needs could be met. People were only admitted to Northwood after their needs had been assessed to make sure that they could be properly cared for at the home. Everyone living at the home had a care plan to tell staff what care they needed and how they liked to be helped. People said that staff looked after their health very well. A relative said they had no worries about their mother’s health care. The principles of privacy, dignity and respect were put into practice. People living at the home said that staff were polite. Several talked about staff giving them privacy when in their rooms. Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 6 The programme of activities was well thought out to appeal to a wide range of interests and tastes. A number of people living at the home commented that they enjoyed the different activities such as the men’s group and film shows. There was an open visiting policy, which meant that people could see their relatives at any time. Visitors said they were made to feel welcome. People said they were given choices in many aspects of their day. One person said there were no rules about anything. People living at the home were offered a varied and nutritious diet. The chef was runner up in a national competition to award people catering for the care services. People were complimentary about the meals. One person said, “The food is too good, I’ve put on about 5 pounds.” A relative wrote that one of the strengths of the home was, “home cooking with fresh ingredients.” There was a clear complaints procedure and people living at the home said they could speak to senior staff if they were unhappy about anything. Relatives who returned surveys indicated that the management acted upon any concerns they raised. People who talked to the inspector and those who returned surveys were positive about the staff and management team. One person said, “The staff are very good with us.” Another described the management team as brilliant. Over half of the care staff held a nationally recognised qualification in care. What has improved since the last inspection? What they could do better: The staff generally managed medication safely but some improvements were needed to reduce the risk of errors and to make sure that the manager had enough information to carry out thorough checks. The registered person must ensure that they carry out thorough background checks on new staff before they start work in the home. This is to ensure, as Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 7 far as possible, that the staff are fit to work with people who may be vulnerable to abuse. 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. Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 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 Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People thinking of moving into the home received sufficient information to help them to make a decision and staff obtained sufficient and detailed information to understand the person’s needs. EVIDENCE: The statement of purpose, service user’s guide and brochure had been updated. The three documents were available to anyone moving into the home. People who returned surveys indicated that they were given enough information about the home to help them make decisions and they had a contract Detailed information about people’s needs was obtained prior to them being offered a place at the home. Senior staff visited people who were thinking of Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 10 using the service so that they could be sure that the staff and facilities at Northwood could meet their needs. Assessments from health and social services’ professionals were also available on residents’ files. Staff had access to the written assessments and also had opportunities to discuss the needs of new people with seniors. Information on the Annual Quality Assurance Assessment (AQAA) indicated that letters were sent to people to confirm that their needs could be met at the home. Standard 6 was not applicable. Intermediate care is not provided at Northwood. Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 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. 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. People’s health and personal care needs were met in accordance with their wishes but practices for managing medication were not completely safe and could increase the risk of errors. EVIDENCE: Three sets of care records were inspected as part of the case tracking process. All three contained a complete set of 10 care plans that followed the activities of living. Part of the plans were standardised and required staff to highlight applicable problems and goals. Staff then had to write in the actions to be taken. The plans generally provided staff with sufficient direction to consistently meet people’s needs in the way they preferred. However, plans to assist people who had some short-term memory loss were not always explicit enough. The care plans were reviewed monthly. Although the reviews did not provide outcome statements to indicate people’s progress towards meeting their goals, Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 12 plans were amended when anything changed. People using the service, or their relatives, signed their agreement to plans. Information included in the AQAA indicated that some staff had received training in end of life care and new care plans had been introduced to support people at this time. These plans contained standardised, good practice directions. Staff said individual information would be added when the plan became necessary. Care plans included risk assessments for moving and handling, nutrition, pressure sore risk and, where applicable, bed rails. There were usually corresponding plans to minimise identified risks but not in all cases. For example, one person had a history of falls but there was no risk assessment or risk management plan in place. The manager said this was an oversight and would be addressed. People’s ongoing health care needs were monitored and they were referred to outside agencies as necessary. Advice from other professionals was added to the relevant plan so that it became part of everyday care. Survey information indicated that people’s health care needs were met. People using the service said they received the care and medical support they needed and relatives indicated that they were informed of any serious issues. At the time of the visit two relatives said that the home provided good health care. Some staff had received training that covered core care values. They discussed how they upheld people’s rights to privacy and dignity. One gave examples of ensuring doors were closed when they were giving assistance with personal care. Another member of staff talked about the importance of giving people choices. People using the service said that staff were polite and respectful and gave them privacy. One person said he had told staff not to bother knocking when his door was open a bit but they still did. Another said, “You can be private in your room.” A relative wrote that the service was good at respecting the client’s needs and wishes. According to information received on the AQAA, the policies and procedures for handling medication were reviewed earlier in the year. Registered nurses dispensed all medicines. The nurses had all had further training this year to update their knowledge and skills. There were clear records of receipt, administration and disposal of medication. Discussions took place around improving safety by ensuring that two staff checked and signed the disposal records. Medication Administration Records (MAR) charts were generally clear. However, a few charts had been altered to show a change in the dose or frequency of administration of the medicine. There was no evidence that this Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 13 had been authorised by the person prescribing the medication. The instructions had been altered instead of making a new entry. This could increase the risk of confusion and can lead to errors. There were records of medication reviews on most MAR charts. Homely remedies were recorded. Creams and other topical preparations were signed for. There were records to show when people had taken medication out of the home. There were directions for staff to alert them when to administer medication that was prescribed “to be given when required”, which reduced the risk of under or over medicating. A random check found that the stocks of medication in the monitored dose system accurately tallied with the records. It was not possible to carry out an audit of this nature on medicines not in blister packs. This was because there were no records to show how much stock had been carried forward from the previous month. This meant that senior staff could not be sure that any medication left at the end of the month was because stock had accumulated over previous months or because it had not been given. Medicines were stored securely. Storage areas were clean and maintained at the correct temperature. Controlled drugs were stored safely and stocks were accurate as per the controlled drug register. Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 14 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, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff met people’s individual and diverse needs, expectations and preferences. The routines in the home revolved around the residents, who said they were happy with their lifestyle. EVIDENCE: Information about preferred daily routines, interests and religious needs was usually recorded in ‘Getting to Know You’ booklets, although one of the people who were case tracked did not have one. This information, although available to staff, was not always transferred to care plans which may reduce the chance of it being incorporated into daily practice. At the time of the visit, everyone spoken with was satisfied with his or her daily life at the home. One person said, “we have every facility available and we can do what we want.” People were able to make choices about most aspects of their lives and there were no rules about routines. People said they could get up and go to bed when they wanted and could spend time in their rooms if they wished. One person who returned a survey commented that their relative, “seems to be really happy with the way things work.” Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 15 The AQAA outlined a varied programme of social and recreational activities to meet the needs of most people living at the home. Several residents confirmed that there were exercises, games, events and entertainment that they could join in with. There had been a bonfire part the evening before the inspection. A relative who filled in a survey said that the strengths of the service were activities and entertainment. One person talked about the monthly men’s group where they had a take away meal and a few drinks. Another person said that they had been given a lovely birthday party. Activity records showed that people had joined a resident in celebrating Eid. There was an open visiting policy and relatives said they were made to feel welcome. One relative said, “I can come at any time and it is never an inconvenience.” A computer, with a specially adapted keyboard and mouse had been installed for residents’ to use, with plans to assist people to keep in contact with family and friends through email. People living at the home had opportunities to go out with staff in the local community and further afield. Everyone spoken with during the visit was positive about the meals. One person said they were “excellent” and another said, “the food is too good, I’ve put on about 5 pounds.” Relatives also praised the chef, who was runner up in the Caring Chef competition last year. One relative said the meals were brilliant. The chef said he used residents’ comments on surveys and at meetings to help compile the menu. He also spoke to people when they were admitted to the home and kept notes about everyone’s likes and dislikes. The chef had a recognised qualification in nutrition. Records of meals showed that people were offered a varied and nutritionally balanced diet. Special religious or medical diets were catered for. There was an alternative at each mealtime and the chef said people could have something not on the menu if they wished. All kitchen records were in place. Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 16 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. People living at the home were protected by the complaints and safeguarding policies and practices of the home. EVIDENCE: The complaints procedure had recently been updated and provided staff with in-depth information, which included guidance on how to respond to complaints. There was an easy to follow summarised procedure for residents and visitors which was displayed on the notice board. There had been no complaints to the home or to the Commission for Social Care Inspection in the past year. People who returned surveys and those spoken with during the visit said that they knew who to speak to if they were not happy. Several people named members of the management team as someone they would go to. Although some relatives were not aware of the complaints procedure, they all indicated that the service had responded appropriately if they raised concerns about care. Staff had access to the Blackburn with Darwen policy and procedure relating to safeguarding adults. There was also a policy and guidance specific to Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 17 Northwood. The manager said that all staff had received training in safeguarding. Staff spoken with said they would report an allegation to the manager and they all knew who to go to outside of the service if necessary. However, one member of staff indicated that they would commence an investigation and interview the people concerned. This could potentially jeopardise an investigation by the police or other agencies. The manager said this gap in knowledge would be addressed. Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 18 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): 26 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered person was actively working towards improving the environment to ensure that residents had a more comfortable and homely place to live. EVIDENCE: There had been further improvements to the environment. A number of areas had been redecorated and refurbished, in keeping with the age and character of the building. The AQAA showed that people living at the home had helped to choose the wallpaper and carpets in the communal areas and in their own bedrooms. Some essential work had been carried out on the building and new boilers had been installed. Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 19 People living at the home generally picked up on the positive aspects of the environment. For example, one person said they had a beautiful room and another was happy that they had a TV that came with the room. A number of people who returned surveys indicated that the environment could be improved. One person said they were not too happy with the fabric of the building and another wrote that the bedroom had wallpaper peeling off and had not been decorated. The registered person was aware that there were still some shortfalls. Information included on the AQAA showed that the registered person was working through an extensive refurbishment plan and most of the areas would be improved within the set timescales. All double rooms were being used for single occupancy and the registered person was working towards installing en suites wherever possible. It was noted that the bathroom and toilet on the ground floor did not have privacy locks. The registered person said that would be addressed immediately. At the time of the visit the home was clean and tidy. There were no unpleasant odours. People using the service and those who returned surveys said it was usually like that. The manager had carried out an audit to ensure that staff were using all possible measures to reduce the risk of spread of infection. A new policy had been produced and staff had received infection control training. The laundry was sited in the basement, away from resident areas. As recommended at the last inspection the registered person was taking steps to ensure that the walls and floor were easily cleanable. The laundry was adequately equipped for the size of the home and on the day of the visit it was tidy and organised. There was only one person who said that improvements were needed to the laundry service. Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. People living at the home were supported by a consistent and appropriately trained staff team but recruitment practices were not thorough enough to provide safeguards. EVIDENCE: There were mixed views about staffing levels. Information from some people living at the home indicated that staff were usually available when they needed them. One person said they would like to see more staff on duty at night and a relative also commented would benefit from another member of staff. At the time of the visit the manager and staff said there were sufficient staff to meet the needs and dependencies of people currently at the home. People using the service and some relatives commented that most of the staff were very good. One person said that staff were caring and helpful. There was a very low turnover of staff. One relative said that the consistency of staff was one of the reasons that Northwood had been their first choice. Several staff who returned surveys and spoke to the inspector made mention of the cohesive staff team as being one of the strengths of the home. Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 21 Only one care assistant had been employed since the last inspection. Their file showed that they had started work at the home before their POVA first check or references had been received. Other pre-employment checks, such as exploring an incomplete employment history, had not been carried out and not all required documents were kept on file. Another carer was part way through the recruitment process. Their file indicated that the recruitment procedures, designed to safeguard people living at the home, were being followed. Two residents had helped to interview the latest recruit. They said it was a good experience and were happy about the appointment. The induction training programme for new staff followed the 12 week common induction standards and included an assessment of competency. Information included in the AQAA indicated there were improvements in staff training. As previously recommended some training in the safe working practice topics had been updated. Other courses were booked. The manager had also introduced a range of in-house awareness courses to keep people up to date until they could attend a more in-depth course if necessary. Staff said they had attended other training relevant to their roles, for example, continence care, diabetes awareness and end of life care. 80 of care staff were trained to NVQ and one other person was working towards it. There had also been improvements in staff supervision and appraisal. The manager had introduced a formal supervision programme and combined the sessions with skills training. Staff identified training needs and set objectives during their appraisals. Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 22 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and staff benefited from a well managed home. There was a good level of consultation, which meant that people were able to contribute to service development. EVIDENCE: One of the registered providers managed the home on a day to day basis. She was supported by a management team who each took responsibility for a different area of the service. In addition to holding a nursing qualification, the registered person had recently completed the Registered Managers Award. She kept her clinical and managerial skills up to date by attending courses, self-study and by networking. A number of residents and relatives commented on how effective the management team were. One person said Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 23 the senior management was very nice and another said the home was well run. A relative said the management was really good. The home held the Blackburn with Darwen quality assurance award. There were also internal systems for monitoring quality. There were high levels of consultation with people using the service. Surveys were sent out to get people’s opinions on specific topics, for example food, activities and plans for Christmas festivities. The registered person said anything negative would be acted upon immediately and other suggestions would be discussed and added to the overall development plan if appropriate. She was able to give examples of improvements that came about as a direct result of consultation, for example, the installation of a walk in shower. There were records of residents and staff meetings. People’s finances were managed by their families. Personal allowances were not held for anyone. One family sometimes left money for cigarettes if they were not going to be able to visit. The manager said receipts were given for money handed over and records and receipts were seen of any money spent on behalf of the resident. Staff had received fire safety training. The fire system and equipment had been serviced and fire alarms were tested regularly. Records of fire drills showed who attended and the outcome of the drill. One of the management team was doing a fire marshal course in January, which meant that there would be someone taking overall responsibility for fire safety in the home. Servicing and maintenance of equipment was up to date with the exception of the passenger lift, which the manager said she would chase up. Servicing of the electrical installation had only been partially completed. Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 24 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Requirement In order to reduce the risk of errors, handwritten alterations to instructions on MAR charts must be dated and clear and show evidence of having been checked. In order to safeguard people living at the home the registered person must ensure that all required pre-employment checks are carried out and all the required information and documents are obtained before the new employee starts work at the home. Timescale for action 30/11/07 2 OP29 19(1) 30/11/07 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 OP9 Good Practice Recommendations To enable audits/checks to be carried out, there should be a system to show when a new package of medicine has DS0000022475.V350281.R01.S.doc Version 5.2 Page 26 Northwood Nursing Home been started. 2. OP19 The registered person should continue with the planned programme of redecoration and renewal of the environment. Northwood Nursing Home DS0000022475.V350281.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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. 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