Inspection on 19/06/06 for Matthews Nursing and Rehabilitation Unit

This inspection was carried out on 19th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Matthews Nursing and... 08/11/05

Matthews Nursing and... 14/07/05

Matthews Nursing and... 10/01/05

Matthews Nursing and... 06/07/04

Matthews Nursing and... 11/03/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Matthews Nursing and Rehabilitation Unit Epinal Way Care Centre Hospital Way Loughborough Leicestershire LE11 3GD Lead Inspector Mrs C A Burgess Unannounced Inspection 19th June 2006 09:30 DS0000001902.V294005.R01.S.doc Version 5.2 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 DS0000001902.V294005.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 and Care Homes for Adults 18 – 65*. 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. DS0000001902.V294005.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Matthews Nursing and Rehabilitation Unit Address Epinal Way Care Centre Hospital Way Loughborough Leicestershire LE11 3GD 01509 217666 01509 262710 karen@rushcliffecare.co.uk 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) Rushcliffe Care Limited ** Post Vacant *** Care Home 37 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (21), Old age, not falling within any of places other category (16), Physical disability (21), Physical disability over 65 years of age (22), Sensory Impairment over 65 years of age (2), Terminally ill over 65 years of age (2) DS0000001902.V294005.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. No person may be admitted to the home who falls within the category MD unless that person has a diagnosed neurological disorder. No one falling within category TI(E) may be admitted into the home where there are 2 persons of category TI(E) already accommodated within the home No one falling in category SI(E) may be admitted into the home where there are 2 persons of category SI(E) already accommodated within the home To be able to admit the named person of category TI named in the variation application number V10993 dated 20th August 2004 The home may accommodate a maximum of 15 persons falling within the category of MD on the ground floor only. Service Users. The home may accommodate a maximum of 6 persons falling within the combined categories of PD/MD dual disability on the first floor only, within rooms 31 to 36 inclusive to be known as the continuing care unit. No person under 35 years of age who falls within combined categories PD/MD dual disability may be accommodated in the home. 8th November 2005 7. Date of last inspection Brief Description of the Service: Matthews Neurological and Continuing Care Unit is one of three units, situated in the purpose built Epinal Way Care Centre, in Loughborough, Leicestershire. It is a specialist unit for thirty-seven patients/residents with mental disorder, physical disability, and sensory impairment. It provides a safe and caring environment. The unit is bright and clean with a high standard of décor throughout. All patients/residents rooms have en-suite facilities and are large enough to accommodate wheelchairs and any necessary specialist equipment. The unit is situated on two floors with a lift servicing the first floor. The ground floor is a fifteen bedded neurological unit, with an additional provision of a further six neurological beds on the first floor, providing rehabilitation packages for patients with complex, neurological conditions, including acquired brain injury. The remainder of the first floor is a sixteenbedded unit for older persons. The neurological unit provides specialist professional support and equipment of agreed packages of care for individual patients. The unit is staffed twenty-four DS0000001902.V294005.R01.S.doc Version 5.2 Page 5 hours a day by trained nurses and care staff. Situated adjacent to the Loughborough Hospital, and approximately one mile from the centre of Loughborough, the unit is accessible by public transport or car. There is ample parking for visitors. The Statement of Purpose, Service Users’ Guide & Inspection Report are available on request (these provide information on how the agency is organised and what services they provide). The Statement of Purpose, Service Users’ Guide are provided for all new residents. Fees at the time of inspection (as stated by the Acting Manager) for older persons were: £403 - £675 per week. DS0000001902.V294005.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day. An opportunity was taken to look around the unit, view records, policies and care plans and to talk to staff, patients/residents, their relatives and visitors. The primary method of inspection used was ‘case tracking’ which involved selecting three patients/residents and tracking the care they receive through a review of their records, discussion with patients/residents and relatives, the care staff, and observation of care practices. Many of the patients/residents were seen during the inspection. Three of the patients/residents, who were able, and one relative spoken with gave the Inspector their impressions of the home. The Inspector was unable to provide comprehensive, verbal feedback to the acting manager as she was participating in a pre-arranged review. N.B. The word ‘younger’ adult refers to those patients who fall within the age range of 18 – 60 years. Older persons refers to residents who are 60 years or older. What the service does well: Matthews Neurological & Continuing Care Unit, Rushcliffe Care Limited continues to provide a high standard of care for the all of the patients/residents of all ages and needs in their care. It is well decorated and maintained, and provides a safe and homely environment for the patients/residents. Staff are caring and supportive towards the patients/residents and their relatives. Patients/residents’ care plans are detailed and comprehensive to ensure that each patient/resident’s individual and specific assessed needs were fully met. The specific needs of patients with brain injury are well managed and the unit has extensive facilities to support the rehabilitation programmes. Care planning and risk assessment are detailed to ensure that all of the patient/residents’ health, welfare and social needs are met. Staff are well trained and able to meet the patients/residents’ needs. The Senior Manager’s knowledge and enthusiasm, with the support of other healthcare professionals, ensures that the patients/residents receive optimum care on all levels. DS0000001902.V294005.R01.S.doc Version 5.2 Page 7 Comments from three patients/residents and a resident’s relative, during the inspection, were very positive and demonstrated that they were satisfied with the standard of care provided. What has improved since the last inspection? What they could do better: No requirements and only three recommendations were made following this inspection. It is recommended that: • Staff consult with patients/residents or their representative regarding the residents care and ask them to sign agreement with provided plan of care. Patients/residents and their relatives are fully informed and consulted regarding any major changes to the unit and are made ware of forthcoming relatives meetings. Regular recorded fire drills are undertaken, as per company policy and any shortfalls addressed. • • 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. DS0000001902.V294005.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) DS0000001902.V294005.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 & 3 (6 OP). Quality of this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The admission process is well managed thereby ensuring patients/residents’ health, welfare and social needs will be met. that the EVIDENCE: The pre-assessment process, completed by either the manager or a Senior Manager, is detailed and robust and reflective of the aspirations, health, welfare and social needs of the patients/residents. DS0000001902.V294005.R01.S.doc Version 5.2 Page 10 Patients/residents’ files contained detailed records of healthcare needs, with interventions and outcomes for each patient/resident. Health professionals’ visits and advice were recorded in ‘Interagency’ notes. For younger adults the unit demonstrates the capacity to meet individual assessed needs and expectations within detailed assessments and care plans; by interagency collaboration, particularly with the Core Brain Injury Team; by ‘in house’ provision of specialist services and personnel, such as, Occupational Therapists (OT), Physiotherapists, Registered Nursing Staff; and specialist equipment, such as, hoists, high/low profiling beds, pressure relieving equipment and specialist physiotherapy and OT equipment. Advice and information was incorporated into the patients/residents’ care plans. Patients/residents’ and a relative spoken with confirmed that the patients/residents’ healthcare, welfare and social requirements and assessed needs were fully met. The unit does not provide intermediate care for older persons. DS0000001902.V294005.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. Quality of this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Patients/residents and/or their relatives are well informed and supported about their assessed care and are encouraged to participate in the decision making process. EVIDENCE: The unit provides comprehensive care plans and risk assessments, which are regularly evaluated and updated. Care plans provide a focus on the specific DS0000001902.V294005.R01.S.doc Version 5.2 Page 12 and individualised care needs of the patients/residents and demonstrate that acceptable risks are supported, particularly with the younger adults, to enable them to progress towards a degree of independence within their assessed capacity, and in agreement with other members of the healthcare support team. For example - patients, who are able, make their own breakfast, with the support of the OT staff, go out alone in their wheelchair or are supported to spend weekends at home with their families. Patients/residents (who are able) and their relatives are consulted about the care provided. Relatives of patients who are receiving care following a brain injury are consulted about care during the review meetings with staff and the Core Brain Injury Team. However, two of the three patients/residents files did not demonstrate that the patient/resident or their relative/representative, had agreed with the care plan provided, although through the review process and in discussions with the patients/residents and a relative it was clear that consultation and concurrence does take place. Three patients/residents and a resident’s relative said that the care was very good, that staff were very caring and supportive, and that they had no complaints. DS0000001902.V294005.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17. Quality of this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. DS0000001902.V294005.R01.S.doc Version 5.2 Page 14 Patients/residents experience a stimulating and varied life style matched to their individual and specific needs. EVIDENCE: The unit has an activities officer who arranges and supports patients/residents in daily activities, provides one-to-one time to read to patients/residents or take them out, weather permitting. There are televisions, videos, CD players and radios and most patients/residents have their own television. Painting and cake making appear to be popular. Relatives and friends are encouraged to take part in activities and are able to visit at any time for older persons and agreed times for younger adults who undergo therapies and treatments during the day. Birthdays and special occasions are celebrated. A summer fête is being arranged. The patients/residents were following the World Cup and the unit was decorated with England flags. Three of the patients discussed England’s chances and were obviously enjoying watching the matches on the television. The unit provides qualified nursing and healthcare professional ‘in house’ support services, which includes occupational therapy (OT), physiotherapy and speech therapy. The Core Brain Injury Team, in partnership with the multidisciplinary team, the patient, where appropriate, and their relatives, develop programmes of care to enable patients with brain injury to fulfil their own personal potential. Specialist equipment is provided, which includes a physiotherapy room, with specialist and multi-sensory equipment in addition to a Jacuzzi/spa treatment room on the ground floor. Additional specialist interventions, such as psychiatric support, are arranged where necessary, to identify strategies and interventions that ensure that all areas of concern are addressed which may preclude patients from making an optimum recovery. Cultural and religious needs are identified and special diets provided to support specific religious requirements, as observed for one of the residents’ who was case tracked. Staff were observed to be caring and respectful to the patients/residents and one resident and her relative confirmed that staff were respectful and mindful of patients/residents privacy and dignity. DS0000001902.V294005.R01.S.doc Version 5.2 Page 15 Meals for patients/residents are prepared in a central kitchen, which supplies all meals required in the Epinal Way Care Centre. The menu sheets indicated a varied and balanced diet. Special, soft and liquid diets are catered for, as are individual preferences. The dining areas were bright, clean and well decorated and staff were observed to assist patients/residents in a discreet and caring way. Patients/residents are weighed regularly to ensure that their nutritional requirements are being met. All three patients/relatives spoken with were satisfied with the quality and quantity of food provided and said that they enjoyed their meals. DS0000001902.V294005.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) Service users retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicines. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 20. Quality of this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are looked after well in respect of their health and personal care needs. EVIDENCE: Care plans are detailed and reflective of patients/residents’ specific and individual personal and healthcare needs. Contact with other healthcare professionals is well documented. The quality of record keeping is reflective of the high standard of nursing and care observed during the site visit which DS0000001902.V294005.R01.S.doc Version 5.2 Page 17 ensures that the needs of the patients/residents are fully met and that they are treated with respect and dignity at all times. Medication administration is managed effectively within the home’s medication policy and procedural guidelines. Only trained nurses administer the medication. Two drug errors had been recently identified. Appropriate action had been taken, the GP and CSCI informed, and additional medication training provided for the staff involved. The acting manager said that should further mistakes occur by the same member of staff they would be suspended from administering medication and disciplined as appropriate by a Senior Manager. Mandatory training is provided and internal audits are completed to ensure the safe and timely delivery of patients/residents’ prescribed medicines. DS0000001902.V294005.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality of this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Arrangements for receiving and responding to complaints are sound, resulting in satisfactory protection of patients/residents’ rights. EVIDENCE: The home’s complaints process reflects the government’s adult protection guidelines, set out in the local Multi Agency Policy & Procedure For The Protection of Vulnerable Adults from Abuse, No Secrets’ publication. Staff are aware of these procedures and receive relevant training. Complaints and concerns made to the home are dealt with appropriately. It was noted that the unit had received letters and cards of thanks from relatives for the care provided to former residents. Neither the home nor the CSCI have not received any complaints relating to the home since the previous inspection in November 2005. DS0000001902.V294005.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality of this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A comfortable, well-equipped, homely and safe standard of accommodation is provided for the patients/residents. EVIDENCE: DS0000001902.V294005.R01.S.doc Version 5.2 Page 20 The unit is safe and well maintained with many adaptations to meet patients/residents’ specific needs. It is decorated and furnished to a high standard which creates a comfortable and homely environment. There is a satisfactory system of maintenance and refurbishment. Patients/residents’ rooms were clean, well decorated and highly personalised. On the day of the site visit all areas of the unit were clean and maintained to a high standard. DS0000001902.V294005.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35 & 36. Quality of this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff at the unit are patient/residents needs. employed in sufficient numbers to meet the DS0000001902.V294005.R01.S.doc Version 5.2 Page 22 EVIDENCE: Staffing levels, at the point of inspection were satisfactory and above that indicated by the Department of Health Residential Forum Guidelines, and were sufficient to meet the patients/residents’ needs. The acting manager maintains overall responsibility for the home and is supernumerary. The home employs a mixed staff group consisting of Registered Nurses, Care Team Leaders, Senior Care Staff and Care Assistants, supported by domestic and catering staff. There are always qualified nurses on duty. In addition there are OT’s, speech and language therapy staff, physiotherapy staff and a clinical psychologist to ensure that the assessed needs of the patients/residents are addressed. Two residents said that there appeared to be sufficient staff, day and night, to meet their needs and did not identify any ‘thin’ times. Two staff files were checked and demonstrated a rigorous recruitment process, with all the required relevant documentation including an enhanced Criminal Records Bureau check. Staff had undergone induction training, mandatory updates and continued training, such as Health & Safety, moving and handling, medication training etc. to ensure that they were competent to do their job and maintain the health and safety of the patients/residents in their care. Staff receive annual appraisals and the acting manager is arranging that staff will receive regular, recorded supervision to ensure that staff are fully competent to provide the required care for the patients/residents. DS0000001902.V294005.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42. Quality of this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. DS0000001902.V294005.R01.S.doc Version 5.2 Page 24 The Senior Manager, a trained nurse, is knowledgeable and experienced; effectively supervises the acting manager and staff and manages the unit to protect the rights and needs of the patients/residents. EVIDENCE: The current Registered Manager’s post is vacant. An acting manager, who is an experienced nurse has been appointed and is in the process of applying for Registered Manager status. An experienced nurse/Senior Manager is available at all times to provide help, clinical advice and managerial guidance. Patients/residents and relatives are provided with an annual quality audit questionnaire to elicit views regarding the service provided by the unit. The acting manager stated that the last one had been being completed in June 2005 but that she was unaware of the outcome. A relative stated that he had not been given the opportunity to give his views regarding some major changes to the unit regarding additional neurological beds on the first floor, and was unaware of residents/relatives meeting. Adherence to Rushcliffe Care Limited policy’s and procedures ensures that patient/residents’ rights and best interests are safeguarded. Health & Safety Policy and Procedures, such as monthly, recorded fire drills, regular fire alarm tests and hot water checks are company policy, to assure the health and safety of the residents and staff. However, it was noted that, although the last recorded fire drill was on 25th May 2006, these had not be done regularly, in line with company policy. The acting manager acknowledged that this must be addressed to ensure the safety of patents/residents and staff. DS0000001902.V294005.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 X 2 4 3 4 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 3 32 3 33 4 34 3 35 3 36 3 CONDUCT AND MANAGEMENT Standard No Score 37 4 38 4 39 3 40 X 41 X 42 3 43 X 4 4 4 4 X LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 X 3 X DS0000001902.V294005.R01.S.doc Version 5.2 Page 26 NO 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. Standard Regulation Requirement Timescale for action 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 YA6 Good Practice Recommendations The Registered Person(s) are recommended to demonstrate that staff consult with patient/residents or their representative regarding the residents care and ask them to sign the care plan. The Registered Person(s) are recommended to ensure that patients/residents and their relatives are fully informed and consulted regarding any major changes to the unit and are made ware of forthcoming relatives meetings. The Registered Person(s) are recommended to ensure that regular recorded fire drills are undertaken, as per company policy and any shortfalls addressed. 2 YA39 3 YA42 DS0000001902.V294005.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. DS0000001902.V294005.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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