Inspection on 19/11/08 for Hebburn Court Nursing Home

This inspection was carried out on 19th November 2008.

CSCI found this care home to be providing an Adequate 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 17/06/09

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 06/02/2009.

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 19th November 2008 08:15 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 Hebburn Court Nursing Home DS0000039411.V373154.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. Hebburn Court Nursing Home DS0000039411.V373154.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) 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.V373154.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 4th April 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.V373154.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.V373154.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 1 star. This means that the people who use this service experience adequate quality outcomes. Before the visit: We looked at: Information we have received since the last visits on 4 and 11 April 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. Annual Quality Assurance Assessment (AQAA). The AQAA gives CSCI evidence to support what the home says it does well, and gives them an opportunity to say what they feel they could do better and what their future plans are. 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 19 November 2008. This visit was carried out by one Inspector and took seven and a half hours to complete. A pharmacy inspector completed a three and a half hour site visit. During the visit we: Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 7 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 a sample of 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 manager and regional manager what we found. What the service does well: The staff collects information together about the person before anyone moves into the home to make sure they can meet their needs. Staff talk with a range of healthcare professionals to make sure that the physical and mental well being of people living in the home is regularly assessed to make sure their needs are being met. Staff are respectful and sensitive with people when helping them or when speaking to them. Visitors are always welcomed and there are links with the local community. All concerns and complaints are now listened to and all actions and outcomes are clearly recorded. The in house maintenance records and external contract certificates were up to date. Many of the staff have worked at the home for a long time and they have formed a good team and take pride in the work they do. Uses the Nutmeg system to ensure that menus give people living in the home a well-balanced, nutritional, choice of food. There is plenty of food with alternatives available. The home is clean, tidy and a comfortable place to live. Staff said: Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 8 “We try to make sure that we meet clients needs and he care is of the highest level”. “The service provides a warm and welcoming home.” “I am always informed if there are any changes to people’s diets or any special dietary needs of new people.” People living in the home said: “There is always someone to help” “The meals are very nice”. “I always receive that care and support from the staff”. Relatives said: “It’s tip top” “Happy with the care my relative receives” What has improved since the last inspection? What they could do better: The Statement of Purpose and Service User Guide needs to be amended, as there have been changes to management. The quality of the care planning needs to improve and all additional records need to be completed in detail. Care plans need to be reviewed and brought up to date. Information about peoples past lifestyles and choices need to be written down so that staff can continue to support them or help them access help from others. The staff must continue to be supported so that they can feel confident that they will be able to meet people’s needs in a professional manner, taking the principles of a person centred approach to care into account. Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 9 Medication policies and procedures need to be followed so that people receive their medicines safely. Increase the opportunities for people to take part in individual meaningful activities and social opportunities. A detailed programme of how the home is to be redecorated and refurbished is needed so that people have pleasant safe place to live. The design and decoration of the home should follow up to date best practice research to help those with a dementia type illness maintain their independence for as long as possible. The problems with the kitchen water supply and flooring need to be put right. There needs to be stable consistent management so that staff feel that they be confident that they will be able to meet people’s needs in a professional manner, taking the principles of a person centred approach to care into account 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. Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 10 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.V373154.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3. Standard 6 is not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive clear information about the service and a comprehensive assessment of need before admission. This helps them make the right decision about using the 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.V373154.R01.S.doc Version 5.2 Page 12 These now need to be brought up to date, as the management arrangements in the home have changed. Before anyone is admitted to the home a full needs assessment is undertaken by a Care Manager, Home Manager and where necessary the nurse assessor. From this information the staff complete a care plan based on individual needs. The care plans showed that new admissions had detailed assessments completed. Despite a detailed hospital discharge assessment one person was not reassessed by the home and the care plan changed. 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. Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 13 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): 7,8,9,10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Access to health care is satisfactory, but lack of detailed care planning and record keeping does not demonstrate that peoples’ needs are being fully met. EVIDENCE: Each person has a plan of care based on the admission assessment carried out by care managers, the home manager and where necessary nurse assessors. Staff completes 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 assessments. These tools help the staff understand the level of risk each person and helps them complete a care plan. Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 14 Where people have been assessed as needing help with mobility the care plans do not always specify the moving and handling techniques or the specialist equipment needed. Care plans and risk assessments are reviewed and generally updated on a monthly basis. 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. People who have been identified at having lost weight 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 said they would contact the GP and dieticians for 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.” There was no evidence that additional calorific snacks and drinks are given and accepted between meals. Fluid balance charts show that some people only have 600mls, 800mls or 1,000mls of fluid during the day. The charts showed little evidence of people being offered drinks overnight. Appropriate pressure relieving devices are available. Several people have air cell mattresses and cushions to prevent pressure damage. Care plans were detailed and clear when recording improvements to wound care. Advice is sought from, occupational therapists, tissue viability nurses, speech therapists and continence advisors. Visits from the multi disciplinary team are recorded in individual care plans. Staff need to develop care plans to show how peoples previous history and lifestyle affects their current needs and aspirations. Also plans need to show what staff need to do when someone becomes aggressive or distressed. This needs to be done so that all staff give support and care in the same way. Decisions on how care is given are based on health care needs and not on a person centred approach. One person who had returned from hospital had not had their care plan reviewed and up dated despite their care needs changing. Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 15 Everyone has access to all NHS facilities to ensure their healthcare needs can be met. There are regular visits from GP’s and other health professionals including, dentists, opticians and chiropody services. A Pharmacist from the Commission completed a medication audit. The Company have safe medication policies and procedures for staff to follow. There has been a reduction in the use of handwritten entries on the Medication Administration Records (MAR) charts because more are now pre-printed by the supplying pharmacy. All hand written medication entries were signed, checked and countersigned by a second person. This reduces the risk of error when copying information. Some comments on the MAR charts such as “course completed “ were dated but not signed. The majority of medicines with a short life once opened had the date of opening recorded on the container including oral liquid medicines, which reduces the risk of contamination and ensures that medicines remain safe to use. There was no evidence of any duplicated MAR chart. Medicines administration undertaken on the first floor was observed. It was noted that the nurse recorded that the medication had been given before administration rather than after the process had been completed. Only medicines were stored in the treatment room fridge and no clinical samples were present. The fridge was not locked at the time of the visit and the key was in the lock. An up to date list of staff authorised to administer medicines was located in the treatment room, which assists in identifying who has been involved in administration if an error or problem was to occur. A supply of morphine solution was located in the controlled drug cupboard although the entry in the controlled drug register stated that it had been destroyed the previous month. A detailed audit of medication management within the home is in place, which allows any shortfalls in practice to be identified promptly and resolved. Many of the staff have worked in the home for some time and know the people they care for well. All of the care staff worked very hard to make sure everyone was treated with respect and their rights to privacy and dignity maintained. Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. Opportunities to take part in meaningful activities and keep control of everyday decisions are good, and mealtimes are organised. This makes sure people can 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. The home has had an open day, a barb-a que and a summer fete. A monthly newsletter is produced and this is used to record events that are happening in the home. It is readily available so that everyone can see what is going on. Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 17 There was little happening on the day of the visit as it was hairdressing day. Staff see activities as a one-person role. They were not comfortable just sitting talking or reading to individuals. At the moment most of the activities are completed in groups, which are not person centred, nor do they take the needs of people with dementia into account. The Company are 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. There were visitors coming and going all day. One person comes everyday for lunch with her relative and another stays and helps with their relatives care. 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 have a drink or a meal with their relative. 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 status is met. Choices for breakfast included, cereals, porridge, grapefruit, full English, eggs cooked according to individual choices. People could also have bread, toast, preserves and juice, tea or coffee to drink. The choices for lunch were pork chops or chicken pie with mashed potatoes two vegetables and gravy. Choices for dessert included spotted dick and custard, ice cream and yoghurts. The food is sent to each unit in “hot locks” and then plated by staff. People are again offered choices of food at the point of service. All of the meals were of ample portion size and nicely presented. Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 18 Staff said that the finger foods were not always available. This information was passed to the manager to put right. Some of the people on the upstairs unit would have benefited from using adapted cutlery and plate guards to stop food falling off the plate and drinks were slow in arriving. Staff gave assistance in a discreet manner everyone spoken to said: “I like the food” “Good grub” “Always plenty to eat” Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 19 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): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good complaints and protection procedures are in place and effectively followed to ensure that people and their relatives are listened to and protected from abuse. EVIDENCE: The Company have 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 detail of any investigation and actions taken. Three complaints have been investigated since the last inspection .Two have been upheld and one continues to be investigated by the Provider. Staff have had training in Safeguarding Adults. Both the Local Authority and the Provider have investigated three alerts. The Provider has worked with the Local Authority and CSCI to make sure the issues are put right. Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 20 Since the visit in April 2008 staff have completed “Yesterday Today and Tomorrow” training as well as whistle blowing and dealing with challenging behaviours. Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,26. Quality in this outcome area is adequate. This judgement has been made using available 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 and lounges. From the ground floor lounge there is direct access to a pleasant enclosed courtyard garden. Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 22 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 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 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 trolley’s. The brown velour type of chairs in both lounges are also looking worn and are difficult to keep free from stains. The manager confirmed that further work needs to be done especially on the unit upstairs to meet the specific needs of the people using the service. 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. Bathrooms and toilets are close to all communal areas and bedrooms. The flooring in bathroom 2 is split, all of the light cords are grimy and difficult to clean and the showers are not easy to use given the steep access ramp. The laundry was clean and organised and staff knew what steps to take should there be any outbreak of infection. All of the staff take pride in the home and everyone works hard to make sure it stays clean and fresh smelling. Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 23 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): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available 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 forty-one people living in the home, many of them have complex nursing needs. The home has two units that are staffed separately. Since the last visit there has been another management change. The new manager has transferred from another home within the Company and has only been in post for a week. 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. There are sufficient ancillary staff are on duty over seven days. These include laundry, catering, administration, maintenance and an activity person. Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 24 There is some nurse agency use, however the care staff have worked at the home for some considerable time and have formed a stable team who know the people living in the home well. Five staff files showed evidence of Criminal Record Bureau checks, Safeguarding Adult checks, and two written references, proof of identity, professional identity numbers for registered nurses and completed induction programmes. Staff also have a training and development file. These files showed that staff have completed mandatory and specialist training since the last visit. This includes, managing challenging behaviours, whistle blowing, safeguarding adults, infection control, health and safety, catheterisation, safe drug practice and “Yesterday Today and Tomorrow” training. Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 25 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): 31,32,33,35,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Without consistent management there is a lack of leadership and guidance, which means there is only adequate quality assurance systems in place and people may be placed at risk. EVIDENCE: Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 26 There have been several changes to the management of the home during 2008. In January the registered manager was transferred to another home and in February a manager from another home within the Company was appointed. She became registered manager in September 2008.However she has transferred to another service and another manager has been appointed to manage the home. She previously been registered with the Commission but this process will have to be completed again. All of these changes mean that staff have been unsure about what is expected of them and do not have a clear understanding of the areas which need to improve. Comments from the staff included: “We will just wait and see what happens” “Some things have again changed downstairs so there will be more to come” “A new manager always changes things” They also said that she was approachable and they felt that she would listen to what they had to say. The Company have detailed quality assurance systems. Audits are being carried out with shortfalls identified and action taken to put things right. Regular meetings are held and staff are now more aware of their own roles and responsibilities. The AQQA was completed by the previous manger and 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 is lifting under the sink, tiles are grimy and there is not hot water on one side of the kitchen. Staff have had training in safe working practices with records kept. Fire training is completed every three months for night staff and six months for day staff. 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.V373154.R01.S.doc Version 5.2 Page 27 In house health and safety checks are carried out weekly. Water temperatures are recorded to ensure temperatures of 44 C is not exceeded. External service contracts were available and up to date. Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 2 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 3 X 3 X X 2 Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? 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 OP1 Regulation 4,5 Requirement Timescale for action 01/03/09 2 OP7 15 3 OP7 15 4 OP8 12,14,17 The registered persons must ensure that the Statement of Purpose and service user Guide reflect the changes in management. The registered persons must 01/03/09 continue to develop care plans in a person centred way to ensure that peoples’ needs can be fully met. This includes social care plans. 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 31/12/08 ensure that care plans are updated following any changes in their health care needs. This includes reviewing care plans when people return from hospital. The registered persons must 31/12/08 ensure that the staff promotes and maintains peoples health care. Fluid balance and food charts must always be completed to DS0000039411.V373154.R01.S.doc Version 5.2 Hebburn Court Nursing Home Page 30 5 OP9 13,17 6 OP9 13,17 7 OP20 23 8 OP21 23 9 OP32 12,21 10 OP38 16,23 evidence practice. The registered persons must ensure Controlled drugs no longer required are disposed of promptly and recorded appropriately at the time of their disposal. The registered persons must ensure that qualified nurses have supervision training and updating on medication policies within the home. The registered persons must ensure that the communal areas are redecorated and repairs completed to doors and walls. The brown worm lounge chairs need to be replaced. The registered persons must repair or replace the flooring in bathroom 2 and replace a shower door. The light cords which are dirty must be replaced so that staff can clean them easily The registered persons must ensure that there is consistent clear leadership and direction given to staff so that the service can continue to develop. The registered persons must ensure that the flooring in the kitchen is replaced or repaired. The hot water supply repaired and the tiles cleaned and re grouted. 31/12/08 01/03/09 01/08/09 01/03/09 01/03/09 31/01/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 31 1 2 3 OP9 OP19 OP31 Records of administration should be made after medication has been given. This makes sure that there is an accurate record. The registered persons should consider changing colour schemes and provide pictures and signage to help people with memory loss find their own way around the unit. The manager should now progress with application to become registered with the Commission. Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hebburn Court Nursing Home DS0000039411.V373154.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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