Inspection on 17/06/09 for Hebburn Court Nursing Home

This inspection was carried out on 17th June 2009.

CQC found this care home to be providing an Good service.

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

Hebburn Court Nursing Home 19/11/08

Hebburn Court Nursing Home 04/04/08

Hebburn Court Nursing Home 26/06/07

Hebburn Court Nursing Home 22/09/06

Hebburn Court Nursing Home 12/01/06

Hebburn Court Nursing Home 24/08/05

Hebburn Court Nursing Home 14/03/05

Hebburn Court Nursing Home 03/08/04

Hebburn Court Nursing Home 27/02/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Hebburn Court Nursing Home The Old Vicarage Witty Avenue Hebburn Tyne And Wear NE31 2SE Lead Inspector Irene Bowater Key Unannounced Inspection 17th June 2009 09:30 DS0000039411.V375712.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hebburn Court Nursing Home Address The Old Vicarage Witty Avenue Hebburn Tyne And Wear NE31 2SE 0191 428 1577 0191 483 5555 hebburncourt@schealthcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross Care Homes No 2 Ltd 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) Manager post vacant Care Home 55 Category(ies) of Dementia (27), Old age, not falling within any registration, with number other category (28), Physical disability (15) of places Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places: 28 Dementia - Code DE, maximum number of places: 27 2. Physical disability - Code PD, maximum number of places: 15 The maximum number of service users who can be accommodated is: 55 19th November 2008 Date of last inspection Brief Description of the Service: Hebburn Court Nursing Home is a purpose built home situated in a quiet and discreet residential area of Hebburn, at the site of an old vicarage. The rear of the building provides a pleasant garden view and ample privacy. The Home is registered to accommodate older people who require personal and/or nursing care, including up to 15 people with physical disabilities. The home has been registered to care for up to 18 people who have dementia needs and who also require nursing care. A separate unit, named The Rivers, has been developed on the first floor of the home accessible by a passenger lift as well as stairs. The unit is divided in two parts, Tyne View and Wear View. In total throughout the home there are 44 single bedrooms, and 12 double bedrooms that are used for single occupancy. En-suite facilities are not provided but there are adequate toilets and bathroom facilities throughout the building. A large central reception area on the ground floor provides seating, in addition to the large lounge/dining areas, and is available to service users and visitors. Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 5 There is a large patio with seating facilities to the rear of the ground floor lounge. Access for wheelchair users is available throughout the Home. The Home is within easy reach of public transport facilities, and the local shops and amenities. Fees for this service range between £355 and £482 per person per week. Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. Before the visit: We looked at: • Information we have received since the last visit on the 19 November 2008. • How the service dealt with any complaints and concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service and their relatives, staff and other professionals. • We have reviewed our practice when making requirements, to improve national consistency. • Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use services are not being put at significant risk of harm. • In future, if a requirement is repeated, it is likely that enforcement action will be taken. The Visit: An unannounced visit was made on the 17 June 2009. This visit was carried out by one inspector and started at 09:30 and was completed at 15:45. During the visit we: • Talked with people who use the service, relatives, staff, the manager and visitors. • Looked at information about the people who use the service and how well their needs are met. • Looked at other records, which must be kept. • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for. • Looked around the building to make sure it was clean, safe and comfortable. • Checked what improvements had been made since the last visit. • We told the Registered Manager and Regional Manager what we found. What the service does well: Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 7 The staff collect information together about the person before anyone moves into the home to make sure they can meet their needs. Visitors are always welcomed and there are links with the local community. The menus offer a variety of well-cooked nutritious meals. People can enjoy a healthy, well-balanced and interesting diet. Clear information is available should anyone have a concern or complaint about the care or service they are receiving. The registered manager makes sure that all checks and clearances are received before staff are employed. There are good arrangements for supporting people to keep their personal monies in a safe place if they want. The Registered Manager makes sure that quality assurance systems are followed so that people receive a quality of care and their views are taken into account. People living in the home said: “I like living here.” “They look after me.” “The food is good.” What has improved since the last inspection? The Statement of Purpose and Service User Guide is readily available and easy to understand. The quality of the care planning has improved and all additional records including risk assessments are up to date. The administration of medicines is generally well managed and the personal wishes of individuals are considered when administering medicines. The staff are being supported and they are more confident that they can meet people’s needs in a professional manner. There is stable management and staff supervision and meetings have improved their understanding of providing a “person centred” approach to care. Staff receive on going training so that they can care for the different needs of people living in the home. They have completed safeguarding training and feel confident that they can recognise signs of abuse would be able to raise an ‘alert’ and protect those at risk. Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 8 The problems with the kitchen water supply and flooring has been put right and new lounge chairs are being provided. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 9 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 Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive clear information about the service and good assessments of need before admission. This helps them to make informed decisions about whether they want to live in this service. EVIDENCE: The home sets out the aims and objectives of the service in a Statement of Purpose, which is readily available. There is also a Service Users Guide that sets out the values of the home. This makes references to supporting the diversity of needs, cultures, and beliefs of all those involved in the home. Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 11 The home confirms in writing to each individual that they can meet their needs and everyone has a contract that sets out the terms and conditions while living in the home. Everyone admitted to the home has an assessment of all their care needs, which is completed by care managers, nurse assessors and the home manager. The assessments provide information about people’s previous life history and health and social care needs. The assessments have been changed so that more detail about preferences and cultural preferences are included. This information is then used to complete a plan of care for the individual living in the home. Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care is being planned in a respectful and person centred way. This enables people to fully access healthcare and other services and ensures their needs are supported. EVIDENCE: Each person has a plan of care based on the admission information which was carried out by care managers, the home manager and where necessary nurse assessors. Staff complete pressure ulcer risk using the Braden scoring system, dependency, moving and handling, nutritional assessments, using the Malnutrition Universal Screening Tool (MUST), continence and fall risk Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 13 assessment. These tools help the staff understand the level of risk so that they can complete a care plan for each person. The staff have worked hard to improve the care plans since the last visit to the home. They are working with the service user and their relatives to find out about their previous lifestyles and histories. This information will then used to show how show how they are promoting people’s independence and choices about daily living. The manager is aware that further work is needed in this area. Where people have been assessed as needing help with mobility the care plans specify the moving and handling techniques and the specialist equipment needed. This means that the person receives consistent safe care. When a person had a fall, resulting in a fracture, the appropriate people were informed and action taken to try and prevent the same accident happening again. Care plans and risk assessments are reviewed and updated on a monthly basis. People also have regular reviews of their care with help from care managers, relatives and staff. Comments include “happy with the care”, “enjoy the food,” and “satisfied with the care, no problems”. Staff have contacted the Speech and Language Therapists (SALT) when there have been concerns about people having difficulty swallowing and being at risk of choking. Detailed information from the SALT team is available in the care plans. Staff were observed following these directions by thickening fluids and making sure individuals have the appropriate soft or pureed diet. Some people who have lost weight or have poor appetites have risk assessments in place to show how they are being supported with eating and drinking. Weekly weights are recorded and the records show that weights are stable or increasing. Should anyone loose weight the staff contact the GP and dieticians for further advice. Food and fluid charts are completed but do not show what people are offered should they refuse or leave their meal. For example “¼ eaten or refused all.” Details of what food and drinks are actually offered and taken need to be recorded so that staff can be sure individual’s nutritional goals are met. However there was evidence that additional calorific snacks and drinks are given and accepted between meals. For example “offer extra snacks, fortified drinks and high protein diet”. Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 14 There are plenty nursing profiling beds and equipment is in use to maintain people’s skin integrity. Currently one person in the home has pressure damage and the tissue viability nurse is involved in this persons care. Care plans were detailed and clear when recording improvements to wound care. Everyone has access to all NHS facilities to ensure their healthcare needs are met. There are regular visits from GP’s and other health professionals including, dentists, opticians and chiropody services. All of the staff had a good understanding of individual needs and were alert to changes in people’s mood and made sure that support and assistance was given in a discreet sensitive manner. The home has policies and procedures to make sure staff administer all medicines safely. Records are in place for all medicines received, administered and disposed of. Only qualified nurses are authorised to manage medication and they have completed updated training on May 2009. An up to date list of staff authorised to administer medicines was available in the treatment room, which assists in identifying who has been involved in administration if an error or problem was to occur All hand written medication entries were signed, checked and countersigned by a second person. This reduces errors when copying complex information. The staff have sight of all medicines ordered and keep copies of all prescriptions. An audit of Controlled Drugs and the Medicine Administration Records (M.A.R.) showed no discrepancies. Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Opportunities to take part in meaningful activities and keep control of everyday decisions are limited and mealtimes are not organised. This means people are unable to lead full and active lives. EVIDENCE: There is an activity person employed at the home. Activities are displayed and include quizzes, painting, dominoes, darts, bingo, themed nights, and in house entertainment. There is a mini bus which is shared with other homes which lets some people go out and about in the area. There was little happening on the day of the visit as it was hairdressing day, although some were having their nails painted. Staff see activities as a oneperson role. They were not comfortable just sitting talking or reading to individuals. Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 16 At the moment most of the activities are completed in groups, which is not person centred, nor do they take the needs of people with dementia into account. There were no newspapers, magazines, books or any items to pick up, so that people can be stimulated and interested in their environment. The Company is aware that a more personal approach to leisure and social care needs to be developed and is planning more training for the staff. Visitors are welcome at any time and are able to use the lounges or their relatives’ bedrooms for visits. It was confirmed that there are no restrictions regarding visiting times. Many people have brought small items with them making their rooms homely and reflective of their previous lifestyles, religious beliefs or cultural backgrounds. There are dining rooms on each unit and also a small “bar room” upstairs where people and their visitors can have a drink or a meal with their relative, although this is not well used at the moment. Should anyone want to eat their meals in their own rooms this service is readily provided. The dining room tables on the ground floor were well set with tablecloths, napkins, cutlery crockery and condiments for both breakfast and lunch. There has been some improvement upstairs with tablecloths, cutlery and crockery on the tables. There were no condiments or napkins unless people asked for them. The Company uses the “Nutmeg” system, which analyses the content of the menus and makes sure people’s nutritional goals are met. Choices for lunch included steak or ham risotto with boiled potatoes, cabbage and swede. Other alternatives included various sandwiches, salads and jacket potatoes with various fillings. Dessert choices were rhubarb pie and custard, fresh fruit or ice cream. The meal time experience again differed on each unit. Downstairs the staff were organised and the food served appropriately from the “hot lock”. People were offered choices, again at the point of service and support was given is a discreet unhurried manner. Drinks were readily available and the mealtime was a pleasant, quiet unhurried occasion. Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 17 Upstairs people were assisted to the table well before the lunch was ready to be served. Some then became impatient trying to leave the table, others banging constantly on the table and others moving cutlery and crockery about. Once the hot lock arrived staff served the meal according to the meal chosen the day before. No one was offered another choice at the point of service. One person pushed the steak meal away and was given the risotto but this was also pushed away and it was unclear what this person actually had for lunch. The portions were large for the plate size which meant people found difficulty in cutting food up or even getting some on their fork, spoon or even knife. There were no plate guards or adapted cutlery which meant a lot of the food ended up on the table, down people’s clothes or was not eaten as it took too much effort. Drinks were not readily available at first and again choices were not offered. Staff were shouting across the room to each other, for example, “does X want the banana in a sandwich or as it is”, and “I’m going down (to the kitchen) to get A’s biscuits”. This meant some people had to wait even longer for their meal to be served. Old lounge chairs were being changed for new during this time and it was decided that the lounge area would be hovered and the then the carpet shampooed during the mealtime which did not help in creating a dignified pleasant mealtime for anyone. Staff tried to give support and assistance discreetly and improvements were seen when another member of staff came from downstairs to help. The majority of people need assistance and support with their food and a review of the mealtimes needs to be carried out so that staff can be sure everyone has their nutritional needs met and their dignity is not compromised. Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good complaints and protection procedures are in place and effectively followed, to ensure that service users (and their relatives) are listened to and protected from abuse. EVIDENCE: The Company has a detailed complaints procedure, which is easy to understand, and it is readily available in the home. The home keeps a full record of all complaints including details of any investigation and actions taken. There have been no complaints since the last inspection in November 2008. Staff have had training in Safeguarding Adults. The Local Authority is currently investigating one safeguarding alert. The Provider is working with the multidisciplinary team to make sure any issues are put right. Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 19 Staff have completed “Yesterday, Today and Tomorrow” training, as well as whistle blowing and dealing with challenging behaviours. Staff were very clear about what they would do should they have any suspicions or receive any allegation of abuse. Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,26. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is a homely and comfortable place to live but further investment is needed to make sure it remains suitable for the needs of the people living there. EVIDENCE: The home has two units, which have their own dining areas, lounges, bedrooms, bathrooms and toilets. From the ground floor lounge there is direct access to a pleasant enclosed courtyard garden. The upstairs unit was developed to care for people with mental health and dementia care needs. Since then there has only been limited development of Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 21 this unit. Doors have been painted different colours and there are some prompts, such pictures of toilets and baths. Attempts have been made to provide some stimulus when people are walking around the corridors. For example there is a collage of old Jarrow and Hebburn and pictures of film stars, which would prompt memories. Different tactile items have been put on the walls for people to touch and feel. These are stuck on the walls and some people may become distressed if the cannot take them off to hold. Throughout the home the wallpaper and decoration in the corridors is now looking tired and worn. There are dark wood doors and damage throughout from wheelchairs and trolleys. On the day of the visit many of the stained lounge chairs were being replaced and the manager confirmed that there was an ongoing replacement programme. And she confirmed that further work needs to be done especially on the unit upstairs to meet the specific needs of the people using the service. None of the bedrooms have an en-suite facility but there are bathroom, showers and toilets close to all areas. These areas have suitable adaptations for people to use, although the ramps to the showers may be difficult to use due to the steep access. Many of the light cords are grimy and knotted and need replacing so that they can be cleaned regularly to prevent risk of infection. Bedrooms continue to be decorated and new bedroom furniture has been purchased. People have been encouraged to bring small items with them and many of the rooms are highly personalised and homely. There are a number of profiling beds available for those who need nursing care. The laundry was clean and organised and staff knew what steps to take should there be any outbreak of infection. There is a sluice in each unit, both have working disinfectors and the home is clean with no odours. Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels and systems around recruitment, selection and training of staff are good and meet the range of needs of the people using the service and protect them from harm. EVIDENCE: On the day of the visit there were thirty six people living in the home. There are two qualified nurses on duty over a twenty-four hour period and they are supported by a team of care staff, which includes a deputy manager and senior carers. The manager is supernumerary. There are sufficient ancillary staff on duty over seven days. These include laundry, catering, administration, maintenance and an activity person. Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 23 There has been a management change and the present manager has been in post for six months. She transferred from another home within the Company and is also a first level nurse. Staff have worked at the home for some considerable time and given the management changes over the last year are forming a stable team. Four staff files showed evidence of enhanced Criminal Record Bureau checks, safeguarding adult checks, two written references, proof of identity, professional identity numbers for registered nurses and completed induction programmes. New staff are given a handbook which covers all aspects of employment matters. It also covers equality and diversity and valuing that everyone has a contribution to bring to the home. There is a three month probationary period and all staff are required to complete training at least to National Vocational Training (NVQ) level 2. Staff also have a training and development file. These files showed that staff continue to complete mandatory and specialist training. This includes, managing challenging behaviours, whistle blowing, safeguarding adults, infection control, health and safety, catheterisation, safe drug practice and “Yesterday Today and Tomorrow” training. Records show that all staff have formal supervision at least six times a year and also have a yearly appraisal. Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is run by a manager who makes sure that good quality assurance and safety systems are in place. This makes sure that people receive a good quality of care. EVIDENCE: Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 25 During 2008 there were several changes in manager which meant that staff have been unsure about what is expected of them and they did not have a clear understanding of the areas which needed improvement. The current manager is a first level nurse with many years experience in elderly care. She transferred from another home within the Company and has previously been registered with the Commission. She has applied to become registered manager of this home. During the last six months she has worked hard to improve all aspects of the service and introduce a “person centred” approach to care delivery. Regular staff meetings and an open door approach has meant that staff understand what changes are needed and know they have the support to change and improve practice. Comments from staff included: “We have a new experienced manager who really cares about the home and deputy who has been here a long time.” “There is lots of support and training and the home has a good atmosphere.” “I enjoy coming to work and this is the happiest environment I have worked in.” They also said that she was approachable and they felt that she would listen to what they had to say. The last “resident” meeting was held in March 2009 and no one came to the relatives meeting. The manager is available one night a month should anyone be unable to see her during the day and will also arrange to meet people at their convenience whenever possible. Audits of all care and other services are carried out, with action and outcomes recorded. The regional manager visits on a monthly basis and completes a separate report. These reports are to make sure the quality of the home continually improves. The AQQA was completed and returned when the Commission asked for it and it gave a reasonable picture of how the home is to develop over the next year. The arrangements for looking after peoples’ monies are computerised and receipts are available for all transactions. Regular audits take place to make sure the accounts are correct and up to date. The flooring in the kitchen has been replaced, tiles are clean and there is now hot water. Staff have had training in safe working practices with records kept. Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 26 Fire training is completed every three months for night staff and six months for day staff. It would be helpful if staff also recorded if they worked day or night duty. This would assist in making sure the required training was clear and no one’s training had lapsed. A fire risk assessment is available and up to date. Accidents are clearly recorded and the manager completes monthly accident analysis to examine and track any trends. Risk assessments for the safe use of bedrails are available and up to date. Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 27 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 3 X X 3 X 2 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 3 3 3 X 3 3 X 3 Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 28 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 OP12 Regulation 15 Requirement The registered persons must continue to develop social care plans in a person centred way to ensure that peoples’ needs can be fully met. This will mean that staff have the right information to provide individual care and support and that people will be able to take part in events and activities that interest them. The registered persons must review how people are enabled to exercise choices and control over daily routines on the dementia care unit. This will allow people to maintain their independence and dignity. The registered persons must review the mealtime experience on the dementia care unit. This will ensure that people are supported to eat their meals in a quiet, pleasant setting and staff know that their nutritional status has been met. The registered persons must ensure that the communal areas are redecorated and repairs completed to doors and walls. DS0000039411.V375712.R01.S.doc Timescale for action 01/10/09 2 OP14 12 01/08/09 3 OP15 12,16 01/08/09 4 OP20 23 01/08/09 Hebburn Court Nursing Home Version 5.2 Page 29 5 OP26 13,16,23 The registered persons must replace the grimy knotted light cords. This will make sure that they can be cleaned and reduce the risk of cross infection 01/08/09 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 2 3 4 5 Refer to Standard OP15 OP19 OP30 OP31 OP38 Good Practice Recommendations It is recommended that the food and fluid charts detail the food and drink offered, taken and record alternatives accepted and refused. It is recommended that further development of the dementia care unit progresses in line with best practice guidance. It is recommended that a person centred approach to care delivery continues in accordance with Dementia Care guidance. The manager should progress with application to become registered with the Commission. It is recommended that the fire records include if staff work day or night duty to make sure no training laspes. Hebburn Court Nursing Home DS0000039411.V375712.R01.S.doc Version 5.2 Page 30 Care Quality Commission North Eastern PO Box 1251 Newcastle Upon Tyne NE99 5AN National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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