Inspection on 20/08/07 for Netherclay House

This inspection was carried out on 20th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Netherclay House 01/07/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Netherclay House Bishops Hull Taunton Somerset TA1 5EE Lead Inspector Gail Richardson Unannounced Inspection 20th August 2007 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 Netherclay House DS0000016043.V347266.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.V347266.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 vacant Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Netherclay House DS0000016043.V347266.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. 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 oversees the home on their behalf. The Registered Managers position is currently vacant and the manager designate is Siobahn Stewart. 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 provides comfortable and spacious accommodation and 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.V347266.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over 1 day (14 inspection hours) on the 20th August 2007 by inspectors Gail Richardson and Sally Murphy. The previous key inspection took place on 27th November 2006. A tour of the home took place and a selection of bedrooms and all communal areas were seen. There were 36 people using the service currently residing at the home, with 2 people using the service residing in the adjacent bungalows. The inspectors spoke to 11 residents, and 5 members of staff, the Acting Manager and the Registered Provider Mr Allistone were available throughout most of the inspection. All people using the service spoken to, who were able, spoke of the staffs kindness and willingness to help, one person said, “the staff are all excellent “. All residents spoken with stated that they were happy with the care they received. As part of this inspection the inspectors surveyed the opinions of a random selection of residents and their representatives, GP’s, District Nurses and Care Workers. It is noted that surveys were sent to the home prior to inspection but non were returned to the Commission, therefore further surveys were distributed by inspectors on the day of inspection. The inspectors spent time talking to people using the service, visitors and staff and observed that on the day of inspection, people using the service appeared relaxed and comfortable in all areas of the home. It was evident from this observation that these people looked well cared for and attention to detail of personal care was seen. The staff spoken too, stated they felt supported by the management of the home and enjoyed their work at the home. Records relating to care including care plans, staff files, 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. Netherclay House DS0000016043.V347266.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 acting manager 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. Netherclay House DS0000016043.V347266.R01.S.doc Version 5.2 Page 7 The acting manager is required to ensure that a 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. This is to ensure that staff have all the details required to ensure that all needs identified are met. The acting manager is also recommended to support people using the service to be involved in their own care planning process. The acting manager is required to ensure that all creams are named and dated when opened to ensure that the creams are not administered after the expiry date. Medications which are self administered are required to be risk assessed and reviewed as required to ensure that the person using the service and other people using the service are not at risk of accidental ingestion. The acting manager 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 acting manager is recommended to promote the use of one to one activity time for people who remain in their rooms. The acting manager is recommended to ensure that puree diet is served in individual portions that enable to people using the service to identify textures and flavours of each menu choice. The acting manager is also recommended to ensure that staff are available in sufficient numbers to assist people using the service with eating and drinking individually, to ensure each person has a hot meal and enjoys the social dining interaction. The complaints procedure is required to be displayed in the main part of the home and is required to contain the correct contact details of CSCI. The complaints process requires further development to ensure that any investigations are documented in detail and include to what level the complaint is substantiated/unsubstantiated. The acting manager must ensure that a call bell system is arranged for both lounges in the older part of the home. This is required to enable all people using the service to be able to contact staff should they require to. The recruitment process is required to be developed to ensure that the employment history for all staff goes back 10 years to ensure that the people using the service are not at risk of abuse. Regulation 26 visits are to be undertaken by the RI and a copy forwarded to CSCI to ensure that the new management of the home are supported and monitored. It is recommended that accident audits are further developed to identify trends and repeated incidences to promote accident prevention. The acting manager is required to ensure that dental tablets are stored in an appropriate manner and any risks are assessed and appropriate action taken. Netherclay House DS0000016043.V347266.R01.S.doc Version 5.2 Page 8 All health and safety issued identified within the body of the report are required to be addressed to ensure the safety of people using the service Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Netherclay House DS0000016043.V347266.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.V347266.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 home continues to be able to provide prospective residents and relatives with sufficient information in the format of brochures, the Service User Guide and Statement of Purpose for them to make an informed decision about the home. All prospective people who will use the service are required to receive a detailed pre admission assessment by the acting manager to ensure the home can meet the assessed needs identified. EVIDENCE: One residents and relatives surveys received stated that they had received a contract and all felt they had received enough information prior to admission, about the home to make an informed decision. Another person had spent time at Netherclay prior to admission. Netherclay House DS0000016043.V347266.R01.S.doc Version 5.2 Page 11 All service users are offered a visit to the home, relatives or next of kin may visit at anytime. Brochures are given or posted on request. All service users have an assessment prior to admission and depending on identified needs, senior staff and manager will liaise together if any equipment is required. It was observed by inspectors that 2 pre admission assessments did not contain sufficient detail to ensure that all aspects of care had been assessed. The home’s Annual Quality assessment Audit states -Service users are given a month trial at the home and at the end of the trial period a review will take place with service user, senior staff & management. When a new service user arrives at the home an allocated key worker is assigned to develop their care plan and to settle them in at Netherclay House. They are also introduced to other service users to find a favorite place to sit, e.g. dining room, lounge to be with other service users who may have similar interests. At inspection all people using the service who were asked did not know who their key worker was. It was discussed with the acting manager how this system could be promoted. Contracts were examined and contained all relevant details but inspectors advised that the contract contain the specific room number as fees relate to the room occupied. Netherclay House DS0000016043.V347266.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 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each person who uses the service has a care plan, the assessed areas of need were not all reflected in this plan of care and the detail recorded did not ensure that staff could provide a good standard of care. Medication systems were mostly satisfactory. Self medication risk assessments are required to be in place for all people using the service who self medicate. Staff were observed to treat the people using the service with dignity and respect at all times and residents fell well cared for. EVIDENCE: One person using the service returned a survey at the time of report. 5 staff surveys were received, these confirmed that 2 staff were involved in care planning for residents and 3 stated they were not. Netherclay House DS0000016043.V347266.R01.S.doc Version 5.2 Page 13 Inspectors spoke with a visiting health professional, who confirmed that the home communicates clearly and works in partnership with them. 3 responses were received from visiting health professionals and all were satisfied with the overall care provided at the home. One comment made was “I am very pleased with the care”. Care plans are written by senior staff and are reviewed every 3 months. Inspectors recommend that these reviews are undertaken monthly and that people using the service are encouraged to be part of the care planning process. Inspectors viewed 2 care plans in detail and another 6 care plans relating to specific care interventions and health /social issues. Inspectors noted that care plans were adequate for basic care needs but lacked specific detail for challenging and changing issues. Issues identified related to challenging behavior and safety had been identified in the daily record but no care plan had been written 3 days later. It was apparent that staff require further training in care planning as care plans were variable in content and in some cases were not a plan of care but had been used to record contact with other health professionals or incidents which had occurred. A care plan was examined of a service user who had recently died. The plan of care had been regularly updated to meet the changing needs of the service user and all care given had been documented. One comment received was that there is “All staff are excellent- we are very lucky”. A further comment stated that there was “enough staff and that although they were sometimes rushed they were always kind and caring” All people using the service who spoke to inspectors were complimentary about the staff and care they received. One relative survey stated that “They look after my mother very well”. Netherclay House DS0000016043.V347266.R01.S.doc Version 5.2 Page 14 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 is a range of opportunities for social stimulation and residents are supported to join in with organised activities or pursue their own interests. The meals in the home are of a good quality and a choice is available. The acting manager is recommended to ensure that further education is provided around the presentation of puree diets and the staff organisation required to support people using the service who need assistance with eating and drinking. EVIDENCE: The activity program and menu are published weekly and delivered to each persons room, on the day of inspection the people using the service had the opportunity to listen to a singer in the lounge. The activities were also displayed on a board in the hallway and there was a board with photos of outings is placed in reception area. Inspectors noted a musical theme running through the majority of activities, care plans examined noted that people had interest in arts and crafts etc and it Netherclay House DS0000016043.V347266.R01.S.doc Version 5.2 Page 15 was discussed with the acting manager that activities should be based on the choices and preferences of the people using the service. The acting manager confirmed a plan to undertake a social history for each person and use that to base activity choices on. It was further discussed that those people using the service who did not come into the lounge would benefit from some one to one activity time in their rooms. People using the service who were asked confirmed that there were activities they could attend and 2 people confirmed that they are supported to maintain links with the community by visiting relatives at the weekends. One resident stated that there were no strict routines in the home and that they were free to decide how and where they spent their time. Everyone who expressed an opinion stated that they have choice about all aspects of their care and are comfortable to request any particular preferences. The home has access to an advocacy service for those people who may require it’s use. People using the service’s rooms were decorated in a manner, which reflected their tastes and lifestyles. Evidence was seen in some cases of people’s own furniture in their bedrooms. People using the service confirmed that visitors were always made welcome and could visit at any time. Breakfast is served to people using the service either in the dining room or in their rooms and choice is available. Lunch was observed in the dining room and was Corned Beef Hash with a selection of vegetables and dessert was steamed pears and custard. The evening meal was jacket potato with cheese and coleslaw or Cornish pasty and salad or a selection of sandwiches. A person using the service confirmed that although lunchtime did not have a choice of menu that if you did not like the menu option an alternative would be provided. A list has been maintained of service users’ specific food preferences. One comment received was that, “Sometimes the alternatives are not very good, vegetables too crisp and sometimes there are no green vegetable for lunch”. Inspectors observed that wine and soft drinks are served with the meal and that drinks are now available in the main lounges. Netherclay House DS0000016043.V347266.R01.S.doc Version 5.2 Page 16 The meal was served hot and appetising, however the people using the service who required their meal to be pureed was served mixed together in a bowl. It was recommended to the acting manager that puree diet be served in individual portions that enable to people using the service to identify textures and flavours of each menu choice. It was also noted that 2 staff were sat with 4 people using the service to assist with eating and drinking. The acting manager is recommended to ensure that staff are available in sufficient numbers to assist people using the service with eating and drinking individually, to ensure each person has a hot meal and enjoy social interaction. Netherclay House DS0000016043.V347266.R01.S.doc Version 5.2 Page 17 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 17 18 Quality in this outcome area is adequate. 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. The policies do not contain all information required to support the reporting processes. Recruitment procedures protect service users from the risk of abuse. EVIDENCE: The complaints records of the home were examined and confirmed that all complaints were investigated and outcomes reached within an appropriate timescale. People using the service surveys, confirmed that they knew how to make a complaint and were confident that their complaint would be acted upon. Inspectors observed that the complaints procedure is not currently displayed in the main part of the home and is required to do so and the current complaints and whistle-blowing policy must contain the correct contact details of CSCI. The complaints process requires further development to ensure that any investigations are documented in detail and include to what level the complaint is substantiated/unsubstantiated. Netherclay House DS0000016043.V347266.R01.S.doc Version 5.2 Page 18 All staff are trained through induction and on going training provided to support service users to make complaints or make suggestions. Management state in the Annual Quality Assurance Audit that they encourage and support people so that they are able to complain with out blame or fear. All 5 staff surveys confirmed that they had information about protecting vulnerable adults and how you report any concerns about poor care practice or allegations of abuse. All 5 staff surveys received confirmed that they had received a Criminal Record Bureau Check and examination of recruitment files confirms that these check were undertaken before staff commenced employment. One staff had commenced induction prior to the POVA being received and this practice must be reviewed. It was discussed with the acting manager that during the recruitment process that all prospective staff are recommended to provide an employment history for the previous 10 years to ensure that people using the service are not at any risk of abuse. Netherclay House DS0000016043.V347266.R01.S.doc Version 5.2 Page 19 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 good. This judgement has been made using available evidence including a visit to this service. The home is a large building with some parts of the building suffering from wear and tear that would be typical of a building of similar age and usage. Maintenance is seen to be ongoing and the standard of hygiene is good. The gardens are attractively laid out and areas are suitable for people using the service use. EVIDENCE: The home is an older building with an extension built on one side and a further 5 bungalow flats available for residential care. There are 3 communal lounges and 1 dining area, these are well furnished and decorated. The acting manager is confirmed that there are plans for call bells Netherclay House DS0000016043.V347266.R01.S.doc Version 5.2 Page 20 to be sited in the 2 larger lounges. This was also recommended at the previous inspection but has not yet been achieved. Personal accommodation is located on 2 floors of the home and is accessible to people with all levels of mobility. Stairs and lift access is available to each floor. All bedrooms seen by the inspector were comfortably furnished and had been personalised to reflect the tastes of the individual resident. People using the service are able to bring personal effects and small items of furniture with them when they move to the home, which gives rooms an individual homely feel. Some rooms are large and spacious and have pleasant views of the surrounding countryside. Specialist pressure relieving cushions and mattresses were seen were there was an assessed need. All wheelchairs were seen to be clean and maintained. Toilet and bathing facilities are provided in sufficient numbers and were clean and odour free, one bath was not working and required appropriate signage to that effect. The acting manager confirmed that the maintenance repair contractors had been contacted. The home was clean and appeared well maintained. One maintenance staff was seen working on the day of the inspection and it is clear that the home has an ongoing maintenance programme. Flooring is currently being replaced to the ground floor of the extension. The home is set in its own attractive gardens with adequate parking facilities. One person using the service was seen sitting outside as a designated smoking area. People using the service confirmed that the home is always clean and fresh. Netherclay House DS0000016043.V347266.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels at the home are adequate to meet the assessed needs of people using the service and staff training is promoted to support people using the service. The induction process for staff has been developed to meet all aspect of the home. EVIDENCE: The inspectors examined staff rotas for the week of the inspection and discussed with staff and people using the service their views on staffing levels. Both staff and people using the service were confident that staffing levels were adequate to meet the needs of the people using the service but staff were sometimes busy. On the day of inspection there was one senior care staff and 5 care staff plus both acting managers. Also working was 1 cleaning staff and 1 kitchen staff. Recent quality assurance questionnaires seen, indicated that staff are sometimes rushed and do not have sufficient time to spend socially with people using the service. Netherclay House DS0000016043.V347266.R01.S.doc Version 5.2 Page 22 5 staff returned comment cards to CSCI, 4 staff confirmed that they felt they had received adequate induction and supervision when they commenced their job. 4 staff confirmed that they were clear of what the service users needs were and also 5 staff were aware of the duties they must not undertake. The homes Annual Quality Assurance Audit states- ‘Netherclay House tries to ensure that the recruitment of staff is of an appropriate mix. Staff are encouraged to enhance their skills. Staff are given a comprehensive induction program which ensures the staff and service users safety. Staff are encouraged to complete food hygiene, health & safety, abuse, manual handling, fire safety, first aid courses and to enhance their skills to progress in their work within the home. Staff are given the opportunity to do NVQ’s 2,3,4 in care. At Netherclay House we try and encourage honesty and to create a balance in the needs of both service users and care staff and work as a team’. The acting manager suggested that at least 70 of staff have completed an NVQ in care, this percentage is to be confirmed. The induction process was seen to be ongoing on the day of inspection. This programme has been developed to cover all aspects of the home and staff sign to say they have received the induction training. Recruitment procedures are mostly satisfactory (See standard 18) with application forms being completed,2 references received prior to staff commencing employment and Criminal Record Bureau checks being received prior to commencing employment. Netherclay House DS0000016043.V347266.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 35 36 37 38 Quality in this outcome area is adequate . This judgement has been made using available evidence including a visit to this service. All staff, service users and visitors spoken to were positive about the management and felt able to raise concerns and felt that their ideas are listened to. The financial procedures within the home are adequate. Staff receive adequate supervision. Further improvements are required to ensure the health and safety of service users, staff and visitors to the home. EVIDENCE: Netherclay House DS0000016043.V347266.R01.S.doc Version 5.2 Page 24 At present the Acting Manager Kimberley Alistone is supported by the Deputy Manager, Siobhan Stewart, who is currently being inducted into the managers position. Staff confirm that they are able to voice their ideas and if required any concerns are always treated with confidentiality and dealt with in the appropriate manner. As required, the company in accordance with Regulation 26 of the Care Homes Regulations 2001, is required to carry out monthly visits. It is noted that Regulation 26 records were not available in the home. It was discussed with the acting manager that the Responsible Individual for the home Mr Alistone is required to undertake these visits and record his findings. This is required to support the acting and deputy managers. The Commission requests that these records be forwarded to the CSCI offices on a monthly basis. Records seen at this inspection were appropriately and securely stored and staff have access as required. Quality assurance records were seen at inspection and evidenced that questionnaires had been sent out randomly to people using the service. The inspector suggested that a more widespread method of gathering information regarding quality issues be implemented. One accident was noted in a care plan but a record was not made in the accident record book. The acting manager is recommended to ensure that all accidents are correctly recorded. Accident audits were examined and must be developed to enable the acting manager to identify trends and incidences to promote the prevention of accidents. The management of people using the service personal monies was audited and the systems in place were satisfactory. Staff supervision records were examined and evidenced that staff are supervised regularly. Maintenance records were well maintained and up to date, these included: Fire Safety. Alarms systems are checked weekly and the fire system was last serviced on 18/07/07. The Fire Risk Assessment is updated monthly. Emergency lighting is tested monthly. Electrical Safety – The home has a hard wiring certificated which is required to be forwarded to CSCI. The PAT certificate is required to be forwarded to CSCI The lift was last serviced on 05/05/07 and hoists were serviced on 24/06/07. Netherclay House DS0000016043.V347266.R01.S.doc Version 5.2 Page 25 Gas Safety - The home has an up to date annual Landlords Gas Safety certificate dated 04/04/07. Further health and safety issues raised included The storage of dental tablets in service users rooms is required to be risk assessed to ensure that people using the service are not at risk of accidental ingestion. En-suite bathrooms are recommended to run the bath water as a routine maintenance matter to ensure there is no risk of Legionella. 5 staff surveys received stated that they were provided with protective clothing and necessary equipment to do their work safely and cleaning staff confirmed that they had access to COSHH data sheets and had received training in the safe use of chemicals. Netherclay House DS0000016043.V347266.R01.S.doc Version 5.2 Page 26 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 3 3 1 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 3 18 2 3 3 3 2 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 X 3 3 3 1 Netherclay House DS0000016043.V347266.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? no 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 OP3 Regulation 14 (1)(a) Requirement Timescale for action 30/09/07 2. OP7 15(1) 3 OP9 13(2) 4 OP16 22(5)(7)( a) The acting manager 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. The acting manager is required 30/09/07 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 acting manager is required 30/09/07 to ensure that all creams are named and dated when opened to ensure that the creams are not administered after the expiry date. All medications which are self administered are required to be risk assessed and reviewed as required. The complaints procedure is 01/09/07 required to be displayed in the main part of the home and is required to contain the correct contact details of CSCI. The complaints process requires further development to ensure DS0000016043.V347266.R01.S.doc Version 5.2 Netherclay House Page 28 5 OP33 26(4) 6 OP38 13(4)(c) that any investigations are documented in detail and include if the complaint is substantiated. Regulation 26 visits are required 30/09/07 to be undertaken and a copy forwarded to CSCI to ensure that the new management of the home are supported and monitored. The acting manager is required 01/09/07 to ensure that dental tablets are stored in an appropriate manner and any risks are assessed and appropriate action taken. 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 OP7 OP12 Good Practice Recommendations The acting manager is also recommended to support people using the service to be involved in their care planning process. The acting manager 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 acting manager is recommended to promote the use of one to one activity time for people who remain in their rooms. The acting manager is recommended to ensure that puree diet is served in individual portions which enable to people using the service to identify textures and flavours of each menu choice. The acting manager is also recommended to ensure that staff are available to assist people using the service with eating and drinking individually to ensure each person has a hot meal and enjoys the social/dining interaction. The recruitment process is required to be developed to ensure that the employment history for all staff goes back 10 years and that all gaps are explored and documented to ensure that the people using the service are not at risk of abuse. DS0000016043.V347266.R01.S.doc Version 5.2 Page 29 3 OP15 4 OP15 5. OP18 Netherclay House 6. OP22 7. OP38 The home should consider providing a more accessible call bell system to residents with poor mobility who use the lounge, so that they can easily summon assistance in an emergency. 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. Netherclay House DS0000016043.V347266.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Netherclay House DS0000016043.V347266.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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