CARE HOMES FOR OLDER PEOPLE
Nether Hall Nether Hall Road Hartshorne Swadlincote, Derby Derbyshire DE11 7AA Lead Inspector
Steve Smith Unannounced Inspection 10th February 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 Nether Hall DS0000002122.V282300.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. Nether Hall DS0000002122.V282300.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Nether Hall Address Nether Hall Road Hartshorne Swadlincote, Derby Derbyshire DE11 7AA 01283 550133 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) Ashbourne (Eton) Limited Mrs Sheila Elizabeth Smith Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (47), Physical disability (3) of places Nether Hall DS0000002122.V282300.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Persons aged 50 years and over with PD (3) to be accommodated in Bedroom No`s 1, 3 and 8. 2nd October 2005 Date of last inspection Brief Description of the Service: Nether Hall Nursing Home provides personal care with nursing, and can accommodate 50 people, all of whom must be over 65 years of age. However, the Home can also provide places for 3 people with disabilities, aged 50 years and over, within the total of 50 places. The Home is in a rural setting, near to the village of Hartshorne. The property was originally a private dwelling that has been extensively converted and extended into a care home. Accommodation is provided to a good standard across two floors. The upper floor is accessible via a passenger lift, a chair lift or via staircases. Bedrooms are attractively decorated and have been personalised by the current occupants. All except two bedrooms have ensuite facilities. Communal areas are bright and decorated to a good standard. The Home provides a number of lounges and dining areas, as well as a separate smoking area. Residents have access to a well-tended safe garden. Nether Hall DS0000002122.V282300.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place in just over 2 hours. Discussion was held with the Home’s Manager and the Home’s Care Manager. Some of the Home’s records were looked at, and the public areas of the Home were examined. What the service does well: What has improved since the last inspection?
The last inspection of the Home listed 6 Requirements and 5 Recommendations for the Registered Providers to meet. Of these, the Home had met 4 Requirements and 4 Recommendations. They are listed below. Residents’ files now list the name of the keyworker allocated to each Resident in the Home. Staff now more closely record the occasions when they ask, or are asked by other staff, to monitor Residents in the Home. Staff in the Home provided baths, or showers, at the frequency requested by Residents. Residents were also given opportunity to accompany staff, or their own relatives, on trips into town, assuming they were capable of undertaking such trips.
Nether Hall DS0000002122.V282300.R01.S.doc Version 5.1 Page 6 Residents were able to take part in local or national elections, if they choose to do so. The administration of medication and its recording had greatly improved. The Manager said that staff now knocked and waited to be invited into bedrooms of those Residents capable of offering this invite. She also said that on employing new staff to the Home she ensured that all necessary documentation was maintained by the Home. 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. Nether Hall DS0000002122.V282300.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 Nether Hall DS0000002122.V282300.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): These Standards were not examined during this inspection of the Home. EVIDENCE: Nether Hall DS0000002122.V282300.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): Standard 7 & 9. The care provided to Residents was of a good quality, but the Manager needed to ensure that the required records and medication records were maintained for all Residents. EVIDENCE: Standard 7 was not examined during this inspection of the Home. However, while reviewing the Requirements of the last inspection it became apparent that the Registered Providers and Manager had not completed all of the items required in that section of the report: The Manager had not discussed with the Residents or their relatives the limitation of each Resident concerning their ability to make choices, have freedom of movement around the Home, or their ability to make decisions. This item should have been addressed from the inspection report dated 2 December 2003. In the new extension of the Home the Residents had not been given copies of the Residents Guide to the Home, and this was found to be still
Nether Hall DS0000002122.V282300.R01.S.doc Version 5.1 Page 10 the case at this inspection. This should have been addressed from the inspection report of November 2005. At the time of the last inspection, in November 2005, the new extension to the Home carried out its own distribution of medication. On examination at that time many errors in recording were noted. This units medication records were examined again on this visit. The situation had greatly improved, however, the following two issues needed to be addressed: A large number of entries in the record were listed with an ‘O’. The foot of the Medication Administration Record (MAR) sheet stated that this entry was to be defined, but on many occasions no definition had been provided. The MAR sheets also had a number of signature gaps within them. These gaps had not been marked by the Care Manager or addressed by her on the rear of each form on which they had occurred, to show how she had addressed the problem and its result. Nether Hall DS0000002122.V282300.R01.S.doc Version 5.1 Page 11 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): These Standards were not examined during this inspection of the Home. EVIDENCE: Nether Hall DS0000002122.V282300.R01.S.doc Version 5.1 Page 12 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): These Standards were not examined during this inspection of the Home. EVIDENCE: Nether Hall DS0000002122.V282300.R01.S.doc Version 5.1 Page 13 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): These Standards were not examined during this inspection of the Home. EVIDENCE: Nether Hall DS0000002122.V282300.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): Standard 27. The Registered Providers were not providing sufficient care staffing, when compared to the Residential Forum, to meet the assessed needs of Residents. EVIDENCE: Staffing provided in the Home was compared with the details provided by the Residential Forum. This showed that during the two weeks beginning 16th and 23rd of January 2006, the Home was providing care staffing just above that required by the Residential Forum for all 50 Residents at the Medium Dependency level. However, the Home was not meeting the suggested staffing level, during these two weeks, if the Home was caring for 25 Residents at the Medium Dependency level and 25 Residents at the High Dependency level. The Registered Providers and Manager are recommended to improve the staffing provided within the Home. These figures were calculated without the Manager’s working time included, as recommended by the Residential Forum. It was also found that 6 care staff, and 2 nursing staff, across the two weeks, worked a number of double shifts of between 12 or 13 hours for each shift. However, none of the staff worked an excessive number of hours each week. During such long shifts it is felt that this would not encourage staff to meet the needs of Residents in a kindly, understanding and patient manner. Nether Hall DS0000002122.V282300.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): Standard 31, 35 & 38. The Manager was appropriately qualified and the Registered Providers regularly ensured that the Home was inspected, to ensure good standards were maintained for Residents. EVIDENCE: The Manager was able to say that she had completed her training to NVQ level 4 in Management. It was also found that the Registered Providers ensured that the Home was ‘inspected’ on at least a monthly basis, reporting any concerns to the Manager. A small amount of Residents money was kept in the Home for everyday expenditure. Records of these were examined. Money were appropriately stored and securely held. Records were kept, and a sample of these was examined, and found to be satisfactory. Nether Hall DS0000002122.V282300.R01.S.doc Version 5.1 Page 16 The training provided for staff was examined. This showed that the Registered Providers and Manager had ensured that all staff, where necessary, had received the required training in Moving and Handling, Fire Safety, Food Hygiene and Infection Control. All nursing staff provided First Aider cover in the Home at all times. However, care staff had not been trained in First Aid. In addition to the basic training to be provided by the Home, the Manager said that staff had also undertaken training in Health and Safety, Pressure Sores and Ulcers, Challenging Behaviour, Customer Care, Care Planning, Dementia Awareness, Nutrition, the Protection of Vulnerable Adults and the Control of Exposure to Hazardous Substances. All Residents had been risk assessed to determine their vulnerability and measures had been put in place to provide protection where necessary. The Home had complied with all necessary legislation, such as the Health and Safety at Work Act 1974, and the Manual Handling legislation of 1992. The Manager said that risk assessments had been carried out to ensure that safe working practices were provided within the Home that related to the care staff, catering staff or domestic staff tasks. She also said that she had provided a written statement of the policy, organisation and arrangements for maintaining those safe working practices. The Manager ensured that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. She also had ensured that fire safety notices were posted in relevant places around the Home. Nether Hall DS0000002122.V282300.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 2 8 X 9 2 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 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 2 Nether Hall DS0000002122.V282300.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Yes 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 Each file must contain details of the limitations made by the Home, and agreed by each Resident or their Representative, on the Resident’s choice, freedom and decision-making ability. (This issue should have been addressed from the inspection report dated 2 December 2003) All Residents must be given access to the Residents Guide to the Home. (This issue should have been addressed from the inspection report dated 2 November 2005) On the Medication Administration Record (MAR) sheet the figure ‘O’ must be defined at the foot of the sheet, whenever it is used. Whenever the Home’s Care Manager investigates signature gaps on MAR sheets she must mark each gap and address the issue on the reverse of each sheet, saying why a signature gap occurred and how it was resolved. Timescale for action 1 OP7 17 Sch 3 07/04/06 2 OP7 5 07/04/06 3 OP9 13 07/04/06 4 OP9 13 07/04/06 Nether Hall DS0000002122.V282300.R01.S.doc Version 5.1 Page 19 5 OP38 13 & 18 All care staff must receive training in First Aid, at least once every three years. 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard OP27 Good Practice Recommendations The Registered Providers and Manager should review the level of staffing provided within the Home against the figures provided by the Residential Forum. Staffing would need to be provided in line with the number of Residents care for in the Low, Medium and High Dependency levels. The Manager should review the length of time care staff are allowed to work each day, and where possible limit this to no more than approximately 8 hours each day. 1 2 OP27 Nether Hall DS0000002122.V282300.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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