Inspection on 01/07/08 for Netherclay House

This inspection was carried out on 1st July 2008.

CSCI found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Netherclay House 20/08/07

Netherclay House 27/11/06

Netherclay House 22/12/05

Netherclay House 06/07/05

Netherclay House 26/01/05

Netherclay House 08/06/04

Netherclay House 03/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Netherclay House Bishops Hull Taunton Somerset TA1 5EE Lead Inspector Gail Richardson Unannounced Inspection 09:30 1st July 2008 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 Netherclay House DS0000016043.V362411.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. Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Netherclay House Address Bishops Hull Taunton Somerset TA1 5EE 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) 01823 284127 01823 336765 Mr Peter Howard Wilmot-Allistone MRS LAURA WILMOT-ALLISTONE ****Post Vacant**** Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named service user under the age of 65 years. Rooms 14, 15 and 16 are suitable only for service users who have a degree of physical and mental independence. The Manager must conduct regular assessment and review of service user needs, to ensure that the accommodation and service provided continues to be appropriate. 20/08/07 Date of last inspection Brief Description of the Service: Netherclay House is a Georgian building with modern extensions that has been a residential home since 1972. The Registered Providers at this time are Mr and Mrs Wilmot-Allistone however Mr Patrick Allistone and Mr Richard Allistone are described in the homes documentation as partners and Richard Alistone oversees the home on their behalf. The Registered Managers position is currently vacant. The home is registered with the Commission for Social Care Inspection to provide personal care to up to 42 people over the age of 65 years. The home provides accommodation for up to thirty-seven service users within the main building, and a further five service users within the bungalows set in the grounds. The home provides meals to persons in their own home as part of the providers Domiciliary Care Agency. Day care is also provided for up to two people per day, which is not registered or inspected by CSCI. Netherclay House currently offers day care, respite care and permanent accommodation. The home does not provide nursing care. Netherclay House is set in large gardens that border the River Tone. The current fee range is £375.00 to £550.00 per week. This fee depends on the size of room and does not include hairdressing, private phone installation and calls, accompanied outings, toiletries , dry cleaning, electrical equipment tests and chiropody. Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This was an unannounced inspection, which took place over 1 day (14 inspection hours) on the 1st August 2008 by Regulation Inspector Gail Richardson and Regulation Inspector Lesley Jones. A tour of the home took place and a selection of the bedrooms and all communal areas were seen. There were 34 people currently residing at the home receiving personal care, 3 people were currently in hospital. There were no people receiving respite care at the time of inspection. The inspector spoke to 6 people using the service, 1 visitor and 7 members of staff, the Manager Designate was available throughout the inspection. The home has provided CSCI with a completed AQAA (Annual Quality Assurance Audit), which was completed by the Manager and gives details of aspects of the home. As part of this inspection the inspector surveyed the opinions of a random selection of people using the service and their representatives, GP’s, District Nurses and Care Workers. Surveys were sent to people using the service and good levels of responses were received, a selection of these responses will be used within this report. Records relating to care including 6 care plans, 3 staff files, 3 items related to finances and health and safety records were examined The focus of this inspection visit was to inspect relevant key standards under the CSCI ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are; - excellent, good, adequate and poor. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The registered provider is required to update the homes statement of purpose, service user guide and terms and conditions of residency to reflect any environmental limitations to access to the lounge areas, these limitations include wheelchair access through the house to the main lounges. This is required to ensure that prospective people using the service are clear about the services available. Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 7 The registered provider must ensure that pre admission assessments are completed in sufficient detail to ensure that the home can provide the care for the needs identified. Furthermore, the registered provider is required to ensure that plan of care is in place for each person using the service which is fully completed, regularly updated and contains all the relevant detail for each identified need. The involvement of the person and their relatives/representatives is also recommended. These requirements and recommendations have not been met since the previous inspection. Three requirements have been made regarding medication practices. These include ensuring a safe procedure for the storage of the medication keys. These requirements have been made to ensure the safety of people using the service. A previous recommendation made regarding the provision of activities has not been acted upon and has been repeated at this inspection. The registered provider is required to ensure that the homes policies for abuse awareness and safeguarding vulnerable adults is in line with the regional policy to promote the safety of people using the service and reduce the risk of abuse. The home have since confirmed that this is in place. Two requirements and three good practice recommendations have been made regarding the environment. These have been made to promote the health and safety of people using the service. The registered provider is required to ensure that regular reviews of dependency levels take place and staffing levels adjusted to reflect that dependency. This is required to ensure the safety of people using the service and enable sufficient staff to be available over any 24 hour period. The registered provider should ensure that staff receive supervision no less than 6 times per year. The registered provider is required to ensure that personal monies are recorded and audited regularly to ensure that a clear audit trail is available at all times. Two requirements and one recommendation have been made regarding health and safety. These requirements cover areas including COSHH practices, Fire drill checks and maintenance of portable appliance testing. 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 Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 8 be made available in other formats on request. Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 3 4 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes Service User Guide, Statement of Purpose and contract of residency require updating to ensure that prospective people can make an informed decision about the home. All prospective residents receive a pre admission assessment by the Manager Designate. These assessments require further detail to ensure that the home can meet the needs identified. EVIDENCE: The home has in place a Service User Guide and Statement of Purpose to enable prospective people using the service and their relatives/representatives to make an informed decision about the home. The service user guide is required to be updated to reflect environmental restrictions to some areas of the home. Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 11 The document does not reflect that rooms in the extension of the home do not have indoor wheelchair access to the lounge. Should wheelchair access be required then staff have to assist the wheelchair user around the outside of the building to access the lounge. There is no covered external access to the lounge, one person using the service stated in a survey that ‘The home not appropriate access for lounge and outside therefore difficult to join in’. The Manager Designate stated that this is verbally informed when people view the home. This is not documented or agreed within the terms and conditions or residency. It was also confirmed by the Manager Designate that there are people currently residing in the extension who require wheelchair access to the lounge. These documents also require updating to reflect that CSCI has superseded NCSC as the homes regulating body. Contracts were examined at this inspection contained details of terms and conditions or residency and included the fees charged for each room. The choice of room is reflected within the range of fees and it is recommended that this be made clear, that should a change of room be required there may be a reflection on cost. 1 Residents survey received stated that they had received a contract and 1 had not . 2 felt they had received enough information prior to admission about the home to make an informed decision. 5 relatives felt they had received enough information. One person using the service commented, ‘I have not regretted moving here’ and another stated ‘The contact is clear and understandable’. The manager confirmed that people are able to visit the home and spend time there before they make a decision on residency. The pre admission assessment for a recent admission to the home was examined. This had taken place to ensure that the home could meet the prospective persons social, health and care needs prior to admission. The assessment required more detail to ensure that the home could identify and assess if the needs could be met. In one area the assessment stated that personal care was ‘good’ and also that continence was ‘good’. The care plan went on the identify needs in those areas. Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Each person using the service has a care plan. Further development is needed to ensure that all areas of assessed need have an appropriate care plan to ensure that people using the service are not put at risk. Staff were observed to treat service users with dignity and respect at all times and residents fell well cared for. Medication systems require further review to ensure the safety of people using the service. EVIDENCE: When asked do you receive the care and support you need, 1 survey said always and 1 said usually, both responded that staff listen and act on what the residents say and both felt they usually received the medical support they needed. Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 13 When asked if the care home meet the needs relatives said,3-always and 5 usually. Comments from relatives included: ‘I am generally extremely happy with the standard of care at Netherclay. Obviously its not perfect but nowhere would be. My relative is clean, well fed and has a lot of company which is very important to them.’ ‘I could give many examples when I have been surprised and delighted by the litt1e extra touches I have seen e.g. Sun cream and straw hats produced when its sunny, a bunch of blue bells on my relatives coffee table, a big kiss and a hug from a carer.’ Comments from people using the service included; ‘Staff are very helpful and considerate’ and ‘the carers are always very good. They are accommodating to my needs’. Staff comments included; ‘I think it is a good home, the clients are well looked after and get anything they need’ Visiting health professional commented that ; ‘The home provides a happy safe caring environment’ and ‘The staffs professional service enables me to provide the best medical care for the residents’. The home has implemented a new care planning system and considerable work has been done to develop care planning. 6 care plans were examined; each person has received a needs assessment and a care plan developed from that assessment. Most areas of identified need had an associated care plan. However, not all areas which had been identified in the assessment or daily records had a care plan in place, this was discussed with the Manager Designate to ensure further development takes place to include all areas within the care plan. In one case a person was clearly identified to have specific needs relating to digestion and elimination, no care plan was in place to support staff to meet those needs. Another person had a significant weight loss but no care plan was available to advise staff in how to address this issue. Two care plans were seen of people who required pressure area care. The care plans did not advise staff of how often this should occur and the changes to observe for. These shortfalls can present a risk to people using the service. Some risk assessments were in place to ensure that independence can be maintained in the safest possible way and a daily record was maintained for each person. Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 14 The homes AQAA (annual Quality Assurance Audit ) states that the homes has improved By introducing a new care planning system and encouraged staff and service users to participate more in their care planning process. Of the 6 care plans examined only one had evidence of the input or a relative/ representatives being consulted in the care planning process and the routine monthly reviews. Support was evident from visiting health professional where a need had been identified and records were maintained of GP and District Nurse visits. The inspectors spent time observing the care being given and noted that the members of staff treated people using the service with dignity and respect at all times. People using the service appeared relaxed in the company of the staff and the atmosphere was happy and calm. Specialist equipment had been provided where a need had been identified, this included pressure relieving equipment and medication aids. Medication systems require further review to ensure the safety of people using the service. When the inspector looked at the Medication Administration Records she found the homes keys, which included the keys to the Controlled Drug Cupboard, stored loosely in the medication records in an unlocked room. This is very poor practice and may place people using the service at risk. The home has written protocols in place on the Medication Administration Records for the administration of most medications. There were no gaps evident in the Medication Administration Record and the record is regularly audited. It was observed that on one record chart the dates had been altered and were not identifiable. This practice could place that person at risk and must not be continued. There was evidence of variable doses being recorded and hand transcribed entries being signed by 2 staff. This is required to enable a clear audit trail of the date of medication commencement. Disposal of medication is recorded and is recommended to be signed by 2 staff members. The home does not currently sign to confirm administration of prescribed creams. This is required to ensure a clear audit trail of medications being administered. The Manager Designate is required to ensure that a system of recording creams administered is commenced. A homely remedy policy is in place with signed consent on agreed protocols by the relevant GP’s. Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 15 Risk assessments are in place for people using the service who self-administer medication and lockable storage is provided. Netherclay House DS0000016043.V362411.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 adequate. This judgement has been made using available evidence including a visit to this service. There are opportunities for social stimulation and people are supported to join in with organised activities or pursue their own interests. The choice of activity appears limited in range. The recording of activities is recommended for further development to promote a person centred approach to activity planning. The meals in the home are of a good quality and a range of choice is available. EVIDENCE: Resident’s surveys asked are there activities arranged by the home that you could take part in; only 1 responded and said never. Comments about activities from people using the service included ; ‘I have never verbally been asked to join activity’ another said ‘I do not participate due to incapacity, but there is a programme of events for you if you wanted to or where able to.’ Staff comments included; Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 17 ‘I think they could do with a little more entertainment and more outings’ another said, ‘I think the home is in a lovely setting. It is nice to see them sat outside in the summer with their hats and drinks.’ The Manager Designate confirmed that no activities were planned for the day of inspection. The inspectors saw that a weekly newsletter is printed; this includes updates of activities planned and the forthcoming menu. There was no menu or newsletter available for the week of inspection. Activity plans for the previous month were available and showed that there were 10 planned activities last month. All were musical apart from one film and one arts and crafts event. There is no dedicated activity staff employed at the home. It is planned that a staff member undertakes this role for an undefined period of hours per week. Life and social histories are available within each persons care plan but these are not used to direct activity planning and so activities do not appear person centred, the Manager Designate confirmed that staff undertake activities as time allows. There is access to a visiting member of clergy, however this was not identified of which faith this was and if there was identified access to any other religious organisations. The Manager Designate is recommended to review activity provision to ensure that people using the service’s choices and preferences are catered for, this must include provision for one to one time for people who remain in their rooms. Recording of activities is also required to ensure that a more person centred approach to activity development is used. Relative surveys asked if the home helps their relative to keep in touch 2always and 4 - usually. People using the service confirmed that visitors are welcomed at any time and they are supported to maintain contact with relatives and friends. Comments from relatives included ; ‘A member of staff usually rings, they try and help my relative on the phone’ Another stated, ‘They need to improve phone answering, occasionally there is no one there’. Review of the homes AQAA states that the home provides; A list of likes and dislikes displayed in the kitchen for individual service users and recorded in the care plan. Cold drinks are served in communal areas. An improved menu is displayed and gives information on meals incorporating special diets and also the opportunity for choice. By offering a wider choice in the evening menu. One to one feeding at mealtime for those service users who need assistance with the intake of nutrition and fluids. This also promotes social interaction. Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 18 Pureed food is presented in individual portions so as to not only identify textures and flavours and promote dignity. Resident’s surveys asked if residents like the meals at the home 2 said usually. Comments included; ‘The food is excellent and although I call in unannounced at any time there always is coffee and often home made cake on offer.’ ‘Very good with feeding the elderly- I have watched them at mealtimes’ Inspectors visited the kitchen and noted that it appeared well organised, clean and well stocked with a variety of fresh and prepared foods. The dining room is pleasantly decorated. People confirmed that they all meals are served in the dining room but people can eat either in the dining room or in their rooms. Staff explained that people who required assistance come to lunch earlier to ensure staff availability to assist with eating and drinking at a unhurried pace. On the day of inspection lunch was beef stew with potato and vegetables followed by desert. The cook confirmed that she was aware of people’s preferences but if anybody wanted an alternative this would be available. On the day of inspection the meal was served hot and appeared plentiful and appetising. Netherclay House DS0000016043.V362411.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. Staff and residents are confident that the homes management team would appropriately deal with any complaints or concerns. Policies, procedures and training are available to staff to ensure they have the knowledge to prevent service users from the risk of abuse. Further update training in abuse awareness is planned. Adult protection policies require updating. EVIDENCE: 7 relatives surveys and 2 people using the service surveys, confirmed that they knew how to make a complaint and surveys confirmed that people knew who to speak to if they were unhappy. 1 relative did not know how to make a complaint 2 Residents surveys confirmed that if unhappy they would know whom to talk too. On the day of inspection all people using the service who spoke with the inspectors, felt able to speak to the staff about any concerns and would feel confident that the issues would be dealt with in an appropriate manner. The home has no ongoing complaints, concerns have been raised with the Commission about the management of the home. Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 20 The complaints policy was displayed within the home and contained the previous contact details for CSCI, the contact details should be updated to ensure that people can contact CSCI if needed. The staff on duty who were asked were aware of the homes whistle blowing policy. In house abuse awareness training has taken place and the training manager stated that 16 out of 22 staff have completed Abuse Awareness training since March 2006. Up date training in this area is planned for this month. The homes abuse awareness policy does not follow the guidelines of the Safeguarding Vulnerable Adults protocol for Somerset (May 2007) and this may affect any investigation or action taken if there is an allegation of abuse. The Manager Designate has since confirmed that this policy is available in the home. Staff recruitment records examined showed that staff had received a Criminal Record Bureau Check and Protection of Vulnerable Adults list check before they commenced employment. Netherclay House DS0000016043.V362411.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 22 23 24 25 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home appears to be mostly well maintained and provides sufficient and suitable facilities but requires further attention to some environmental health and safety areas. The standard of hygiene is good. The gardens are attractively laid out and suitable for people using the service use. EVIDENCE: A selection of bedrooms and all communal areas were seen at this inspection. The home is pleasantly decorated with décor and furnishings of a good standard, the home was clean but appeared worn in some areas. Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 22 The home contracts out all maintenance and does not currently employ a maintenance person to monitor repairs. A volunteer maintenance person is available. The home provides 2 main lounge areas, 2 smaller lounges and a large dining room. Bedrooms seen were of varying sizes and were pleasant and airy. There is mostly level access around the home and people using the service have access to other floors via a passenger lift or stairs. However as discussed in the section Choice of Home the extension to the home does not have indoor wheelchair access to the main 2 lounges and people using the service who require wheelchair assistance have to go outside the home to access the lounge. It was observed that the coffee trolley also had to take this route to access the lounge. Some radiators were observed to be unguarded and may place people using the service as risk of injury. The Manager Designate is recommended to ensure that risk assessments are in place for those areas. The garden area was pleasant and accessible to people using the service. On the day of inspection people were seen to use the garden area by the main door as a place to sit and this is also a designated smoking area. Some parts of the home appeared worn and in need of repair, these included some bathrooms and toilets which need maintenance to ensure there is no risk of cross infection. Comments from relatives included: ‘My relative’s room would benefit from redecoration’ ‘The garden has uneven steps, raised edges uneven paths and flower tubs which people fall over.’ ‘A bit of attention to worn and faded curtains/carpets/chairs/shades etc. should ‘tart’ the place up a bit’ Comments from people using the service included ‘Some aids in bathroom could have been better to aid greater independence. ‘Bathroom small for wheelchair access’ ‘Home not appropriate access for lounge and outside therefore difficult to join in’ There are suitable and sufficient toilet and bathing facilities. The downstairs Parker bathroom was noted to have a net curtain over a small window. The inspectors were able to observe a person being assisted into the bath through this curtain, the Manager Designate is recommended to review this area to ensure the privacy and dignity of people using the service. Bedrooms were personalised with service users photographs and some small personal belongings and pieces of furniture and TV’s and call bells were available in each room. Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 23 It was noted that one bedroom door did not a safety lock in place and instead had a lock which may make the room inaccessible from the outside and so may place the person at risk. The Manager Designate is recommended to audit all locks to ensure that safety locks are available in all areas of the home. One room was noted to be very dark with no immediate access to a bedside light. The Manager Designate is recommended to audit all rooms to ensure that adequate lighting is available to support people using the service. Call bells were seen in the larger lounge however one call point did not have a call lead. The adjacent lounge did not have a call point and this is required to be addressed to ensure the safety of people using the service. The homes AQAA states the home has improved by; All replacement flooring has been completed in the new part of Netherclay House. In an on going program of updating 10 rooms have had flooring replaced. 4 rooms have been redecorated which is also an ongoing program. 3 rooms have had energy and safety efficiency programs carried out by relocating radiators. Main electrical circuit boards have been replaced in the old part of the house. Access is available to a small upstairs flat. No signage or restricted access is evident and may present a risk if accessed by people using the service. Appropriate action is recommended to ensure the safety of people using the service. Both residents surveys confirmed that the home is always clean and fresh. One person commented ‘Standards of cleanliness are generally good’ Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 24 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 adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels at the home are not related to the dependency levels of the people using the service. Staff training is promoted to support people using the service. The induction process for staff is developed in line with the Skills for Care, Common Induction Standards and staff training is ongoing. The recruitment procedures within the home protect the people using the service from risk. EVIDENCE: Both Resident’s surveys when asked if staff were available when you need them said yes. There has been a recent turnover of senior staff and recruitment is taking place. Agency nurse use is minimal. On the day of inspection there were 6 care staff including a senior carer in the morning, the afternoon saw 4 care staff including one senior carer and overnight there was either 2 or 3 care staff on duty, concern was expressed by the inspectors that 2 care staff overnight must be evidenced as adequate by the use of dependency assessments to ensure the safety and wellbeing of people using the service. Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 25 Relative’s surveys asked, do staff have skills and experience to care properly? Responses are 3-Always,2- usually. Staff appeared well presented, courteous and polite at all times. People using the service confirmed that staff were kind and thoughtful. One relative commented, ‘Home needs more staff’. People using the service commented that ,’Staff are very helpful and considerate’ and ‘The carers are always very good’. Staff comments included; ‘On own most of the time and has too much to do’ 3 comments were received expressing concern about communication difficulties with staff whose primary language is not English. This was discussed with the Manager Designate to ensure that the home is aware of these difficulties. Staff training records were not up to date, the inspector was later contacted by the training manager for the home who explained that training is ongoing and provided dates to confirm that all mandatory training is up to date. Further training is also available for subjects which included Oral health, Parkinson’s Disease and Communication The homes induction training is in line with the Common Induction Standards and the training manager stated that over 50 of staff have completed NVQ level 2-3. Recruitment procedures were examined and were mostly adequate to ensure that people using the service were not placed at risk. The Manager Designate is recommended to ensure that references are received from the most recent employer to ensure that people using the service are not placed at risk and that all references are signed and dated when received. Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 26 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): 33 35 36 37 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management people using the service monies require regular audit and the systems in place require review. Staff supervision is recommended to be undertaken regularly. Records are maintained in line with the Data Protection Act. Some health and safety procedures need to be reviewed to ensure the safety of people using the service. EVIDENCE: Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 27 Standards 31 and 32 cannot be assessed, as the Manager Designate has not completed the registration process with CSCI. However the Manager Designate has been in post since the last key inspection. The inspectors felt that she did not have a sufficient understanding of the current management of the home to ensure that people’s needs were being met in some areas; these areas were discussed with the Manager Designate at feedback. Comments received which were reflective of concerns raised included ‘We feel it is unfair owner brings personal ‘pay back’ agenda into the home.’ ‘The atmosphere has been rather strained recently due to personal matters concerning a member of the management. Opinions are often freely expressed at this level and not unnaturally confidentiality is expected of the staff’. This area of management must be addressed to ensure that the home is managed in an appropriate and positive manner. The homes AQAA (Annual Quality assurance Audit ) States, we show how we do well by: By sending out six monthly questionnaires to both service users and their families it helps us establish key areas that we are doing well in or need attention. We ensure that the service users are aware of how valued their opinions are. No questionnaires had been sent out since the last key inspection. This is recommended to ensure a clear audit of peoples views on the home. Furthermore at the last key inspection it was required that Regulation 26 of the Care Homes Regulations 2001, visits were required to be undertaken and a copy forwarded to CSCI to ensure that the new management of the home are supported and monitored. This is part of the homes quality assurance requirements. The Provider/ Partner confirmed at inspection that these report would be forwarded to the Commission by a stated time and the reports have now arrived. Personal monies can be stored by the home and a record maintained of all deposits and withdrawals. These records were mostly correct however one record was poorly maintained and appeared unclear. The Manager Designate confirmed that since the staff member who used to manage the finances has left no regular audit of finances has taken place. This is recommended to be undertaken. Records stored at the home are stored securely and in line with the Data Protection Act. Staff are aware of the need for security of confidential documentation. Accident records are available for people using the service and staff. The action taken as a result of an accident is not recorded and risk assessments are not Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 28 seen to be generated in response to accidents recorded. This is needed to promote accident prevention. Supervision of staff was noted to not have taken place regularly and is recommended to be undertaken a minimum of 6 times per year in line with the National Minimum Standards. Fire systems The fire alarm tests were completed for June 2008. Fire extinguishers were last tested December 2007 and are due again in December 2008. Emergency lighting was due testing in June 2008 but no records were seen. The in house weekly alarm test showed a number of gaps which were longer than a week and this is recommended to be recorded weekly. The home has a fire risk assessment dated 14/05/08 and is reviewed annually. The last fire drill is recorded as 10/10/06, this is out of date and required to be reviewed. Electricity The hard wiring certificate is up to date however the Portable appliance Testing was due on the 10/07/08 and has not yet been commenced. Gas He homes gas certificate was up to date Manual Handling Equipment. The homes lifts, hoists and assisted baths were maintained within the year 2008. Hot water Temperatures The hot water systems were tested for Legionella 2008 and the hot water systems inspected 14/04/08. There were no records available for the monthly checking of the hot water outlet temperatures. These checks must be maintained to ensure that people using the service are not at risk of injury from scalds. It was noted during the inspection that cleaning chemicals and a bucket with water was left unobserved for period of time by the door to outside. The Manager Designate must ensure that all substances hazardous to health are stored in line with the COSHH guidance to ensure there is no risk of accidental ingestion. Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 29 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 1 3 2 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 x 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 2 2 3 3 3 3 1 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X 1 2 3 1 Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 30 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. 1. Standard OP1 Regulation 4 &5 Requirement The registered provider is required to update the homes statement of purpose, service user guide and terms and conditions of residency to reflect any environmental limitations to access to thee lounge areas. The registered provider must ensure that pre admission assessments are completed in sufficient detail to ensure that the home can provide prior to admission the care needs identified. Previous timescale 30/09/07 not met. 3. OP7 15(1) The registered provider is required to ensure that plan of care is in place for each person using the service which is fully completed, regularly updated and contains all the relevant detail for each identified need. Previous timescale 30/09/07 not met. 30/08/08 Timescale for action 30/08/08 2. OP3 14 (1)(a) 30/08/08 Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 31 4. OP9 13(2) The registered provider must 30/09/08 ensure that all prescribed creams are signed for on the Medication Administration Records as given The registered provider must 30/09/08 ensure that the medication keys are stored in a secure manner at all times and ensure that all staff are aware of the importance of safe management systems of the keys. The registered provider is required to ensure that the Medication Administration Records are maintained in a manner which promotes the safety of medication administration. Dates must be re written to ensure clarity and not over written. The registered provider is required to ensure that the homes policies for abuse awareness and safeguarding vulnerable adults is in line with the regional policy and is available to staff. The registered provider is recommended to provide risk assessments for all unguarded radiators. The registered provider is required to ensure that all locks used on bedroom doors are safety locks and are not a risk to people using the service. The registered provider is required to ensure that regular reviews of dependency levels take place and staffing levels adjusted to reflect that dependency. DS0000016043.V362411.R01.S.doc 5. OP9 13(2) 12 (1)(a) 6. OP9 13(2) 12(1)(a) 30/09/08 7. OP18 12(1)(a) 30/08/08 8. OP24 12 30/08/08 9. OP24 12(1)(a) 30/08/08 10. OP27 18(1)(a) 30/08/08 Netherclay House Version 5.2 Page 32 11. OP35 12 The registered provider is required to ensure that personal monies are recorded correctly and audited regularly. The registered provider must ensure that all substances hazardous to health are stored in line with the COSHH guidance. The registered provider must ensure that Health and Safety guidance is followed with reference to : The Fire drill requires updating Recording of weekly fire alarm tests. Recording of monthly emergency lighting checks. Testing of Portable Appliances Recording of monthly hot water outlets temperatures. 30/08/08 12. OP38 13(4) 30/08/08 13. OP38 13(4) 30/08/08 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 OP2 Good Practice Recommendations The registered provider is recommended to review the homes contract to ensure that it is clearly stated that different rooms have different fee scales reflective of room size. The registered provider is recommended to include the relatives/representatives of people using the service in the DS0000016043.V362411.R01.S.doc Version 5.2 Page 33 2. OP7 Netherclay House care planning and review process. 3. OP7 The registered provider is also recommended to support people using the service to be involved in their care planning process. The registered provider is recommended to ensure that 2 staff sign for the return/disposal of medications. The registered provider is recommended to review the provision of activities to ensure that they are based on the preferences and choices of the people using the service. Furthermore the registered provideris recommended to promote the use of one to one activity time for people who remain in their rooms. Previous recommendation not yet met 6. OP22 The home should consider providing a more accessible call bell system to residents with poor mobility who use the smaller lounge, so that they can easily summon assistance in an emergency. Previously recommendation partially met 7. OP24 The registered provider is recommended to provide an improved blind or curtain to prevent visual access to the bathroom. The registered provider is recommended to audit the home and ensure that all people using the service have access to appropriate lighting. The registered provider must ensure that staff receive supervision no less than 6 times per year. The acting manager is recommended to ensure that all accidents are recorded. Accident audits are recommended to be further developed to identify trends and repeated incidences to promote accident prevention. Previous recommendation not met 4. 5. OP9 OP12 8. OP24 9. 10. OP36 OP38 Netherclay House DS0000016043.V362411.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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