Inspection on 05/01/06 for Neath House

This inspection was carried out on 5th January 2006.

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

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

Other inspections for this house

Neath House 07/06/07

Neath House 23/09/05

Neath House 31/01/05

Neath House 07/07/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Neath House Currier Drive Neath Hill Milton Keynes MK14 6NS Lead Inspector Nichola Cahill Unannounced Inspection 5th January 2006 09:30 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 DS0000057170.V276738.R01.S.doc Version 5.1 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. DS0000057170.V276738.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Neath House Address Currier Drive Neath Hill Milton Keynes MK14 6NS 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) 01908 607248 01908 231333 Neath Hill Care Centre Jacqueline Blease Care Home 41 Category(ies) of Dementia (28), Old age, not falling within any registration, with number other category (13) of places DS0000057170.V276738.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. It will be a condition of registration for Neath House that the refurbishment will be completed by April 2004. The categories of registration for Neath House will be 28 (DE) 13(OP), all aged 65 and over. All environmental requirements are maintained prior to the refurbishment. Staffing ratios to be maintained and not to fall below the current levels. 23rd September 2005 Date of last inspection Brief Description of the Service: Neath House is a purpose built home situated in a residential area of Milton Keynes. It is close to local amenities and to the town centre. The home is registered to provide care for up to 41 elderly people with 28 beds allocated for elderly dementia type illness. All beds are block purchased by Milton Keynes Council. Accommodation is in single rooms with varied shared social spaces. There is limited garden space. The home is divided into five smaller units, each with its own sitting room/dining area. The home is owned and managed by Excelcare Holdings PLC. There is a planned development for the home. All service users are registered with local GP Practice and have access to local NHS Services through GP referral. DS0000057170.V276738.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a summary of the annual unannounced inspection carried out on 5th January 2006 by Nicky Cahill (inspector) and Gill Gentles (inspector). The inspection commenced at 09.30 and was carried out over a period of three hours. The inspection consisted of an examination of records in accordance with the core standards outlined within this report. All core standards have been assessed during the last twelve-month period. The home has complied with requirements made during the inspection visit in September 2005. One requirement was made during this visit. What the service does well: A clear and comprehensive complaints procedure is in place. Service users and other visitors to the home are able to air concerns and complaints and know that they will be addressed appropriately. The home has a clear and comprehensive policy regarding awareness of abuse. Service users are safeguarded against abuse in accordance with written policies and staff training and awareness. The layout and location of the home is suited to it’s stated purpose, it is accessible and, on the whole, well maintained. There are adequate toileting and bathing facilities throughout the home. The home is kept clean and free from offensive odours, in most areas. Service users are provided with a safe, comfortable and well maintained place to live. There is currently no registered manager working full time within the home due to an organisational restructure, however, the acting manager is fully supported by the organisation and is fully able to run the home in the best interests of the service users. Effective quality assurance monitoring systems are in place and ensure that the home is run in the best interests of the service users. DS0000057170.V276738.R01.S.doc Version 5.1 Page 6 Records required by the commission for the protection of service users are maintained and kept in order. Service users rights and best interests are safeguarded by the homes documentation. The manager ensures, as far as is reasonably practical, that the health and safety of service users and staff is protected. What has improved since the last inspection? What they could do better: 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. DS0000057170.V276738.R01.S.doc Version 5.1 Page 7 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 DS0000057170.V276738.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards from this section were not assessed during this inspection visit. However, during the inspection in September 2005 standards 3 and 4 were assessed and were being met. EVIDENCE: DS0000057170.V276738.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards from this section were not assessed during this inspection visit. However, during the inspection in September 2005 standards 7, 8, 9 and 10 were assessed and were being met. EVIDENCE: DS0000057170.V276738.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards from this section were not assessed during this inspection visit. However, during the inspection in September 2005 standards 12, 13, 14 and 15 were assessed and were being met. EVIDENCE: DS0000057170.V276738.R01.S.doc Version 5.1 Page 11 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): A clear and comprehensive complaints procedure is in place. Service users and other visitors to the home are able to air concerns and complaints and know that they will be addressed appropriately. The home has a clear and comprehensive policy regarding awareness of abuse. Service users are safeguarded against abuse in accordance with written policies and staff training and awareness. EVIDENCE: Then home has a complaints policy and procedure, which was revised in April 2005. This information is available in the front entrance of the home. The home received two complaints in September 2005. From records viewed it would appear that both complaints were dealt with appropriately and in accordance with the policies and procedures in place. The home has a policy and procedure regarding awareness and protection from abuse. This policy is used in conjunction with the local authority interagency policies and procedures. This policy was reviewed in April 2005. All staff, with the exception of two new employees, have completed awareness of abuse training with ‘Affordable Training’. Training is refreshed annually. DS0000057170.V276738.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 26. The layout and location of the home is suited to it’s stated purpose, it is accessible and, on the whole, well maintained. There are adequate toileting and bathing facilities throughout the home. The home is kept clean and free from offensive odours, in most areas. Service users are provided with a safe, comfortable and well maintained place to live. EVIDENCE: The front entrance of the home is spacious and welcoming. Recent alterations have been partially completed providing the home with a new central reception and offices. Other major works have been carried out to enable the home to provide care for a further six service users. This work is due for completion within the near future. During the inspection visit in September 2005 it was noted that some bathing and toileting areas had been affected by the homes refurbishment and alterations. These areas had been left without adequate lighting and ventilation. It had also been noted that one toilet was out of order and another DS0000057170.V276738.R01.S.doc Version 5.1 Page 13 was being used for storage. The tour of this area during the inspection confirmed that these issues had been addressed. It is a requirement that all areas of the home are kept clean and free from hazards. DS0000057170.V276738.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards from this section were not assessed during this inspection visit. However, during the inspection in September 2005 standards 27, 29 and 30 were assessed and were being met. EVIDENCE: DS0000057170.V276738.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 37, 38 There is currently no registered manager working full time within the home due to an organisational restructure, however, the acting manager is fully supported by the organisation and is fully able to run the home in the best interests of the service users. Effective quality assurance monitoring systems are in place and ensure that the home is run in the best interests of the service users. Records required by the commission for the protection of service users are maintained and kept in order. Service users rights and best interests are safeguarded by the homes documentation. The manager ensures, as far as is reasonably practical, that the health and safety of service users and staff is protected. EVIDENCE: DS0000057170.V276738.R01.S.doc Version 5.1 Page 16 The acting manager, Paula Bonner, is fully supported by the organisation and is fully able to run the home in the best interests of the service users. It was confirmed by the regional operations manager that the homes new manager, Tracey Shepherd, would be in post by 31st January 2006. Tracey is presently working within another of the organisations homes and is an experienced registered manager. The organisation completes a visit to the home in accordance with The Care Homes Regulations 2001, Regulation 26. A copy of the report from such visits is regularly forwarded to The Commission. Team meetings are held regularly and minutes for such meetings were available for inspection. The regional operations manager, Kay Shepherd, held a service user meeting on 13th December 2005. It was confirmed that the minutes for this meeting would be forwarded to The Commission in the near future. Records required by the commission for the protection of service users are maintained and kept in order. It is recommended that the acting manager ensures that staff are aware of new policies and procedures in place. The manager ensures, as far as is reasonably practical, that the health and safety of service users and staff is protected. The following health and safety records were viewed. • Monthly hot water checks have been carried out and recorded appropriately. • Portable appliance testing had been carried out on 05.12.05. • Emergency lights had been checked regularly and records completed. • Hoists were serviced on 08.06.05 • Systems were in place for the testing of fire alarms, fire call points and ensuring that regular drills were carried out. The records for accidents and incidents were viewed. It was noted that the home has a relatively high number of falls, which would appear to occur at certain times of the day. The acting manager has liaised with the falls steering group for information and advice on reducing the numbers of falls. It is recommended that the acting manager complete an audit of falls, which will identify any areas of concern that may be addressed. DS0000057170.V276738.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 3 X 3 X X X X 2 STAFFING Standard No Score 27 X 28 X 29 X 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X DS0000057170.V276738.R01.S.doc Version 5.1 Page 18 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 OP26 Regulation 13 Requirement It is a requirement that all areas of the home are kept clean and free from hazards. Timescale for action 28/02/06 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 Refer to Standard OP37 OP38 Good Practice Recommendations It is recommended that the acting manager ensure that staff are aware of new policies and procedures in place. It is recommended that the acting manager complete an audit of falls, which will identify any areas of concern that may be addressed. DS0000057170.V276738.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 DS0000057170.V276738.R01.S.doc Version 5.1 Page 20 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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