Inspection on 10/05/06 for Nethercrest Residential Care Home

This inspection was carried out on 10th May 2006.

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

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

Other inspections for this house

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

CARE HOMES FOR OLDER PEOPLE Nethercrest Residential Care Home Brewster Street Netherton Dudley West Midladns DY2 OPH Lead Inspector Richard Eaves Key Unannounced Inspection 10th May 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Nethercrest Residential Care Home Address Brewster Street Netherton Dudley West Midladns DY2 OPH 0115 922 4333 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) Mimosa Healthcare Group Limited Brenda Essom Care Home 40 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (2), Old age, of places not falling within any other category (32), Physical disability over 65 years of age (6) Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user accommodated at the home may be in the category of MD. This will remain until such time that the service users placement is terminated. 28th November 2005 Date of last inspection Brief Description of the Service: Nethercrest Care Home is privately owned by Mimosa Healthcare Group Ltd, it provides residential care and accommodation, on a shared site with its sister home Nethercrest Nursing Home. First registered in June 1991 the home provides personal care for 40 residents in single rooms on the ground floor and flat-lets on the first floor. The flat-lets offer bedroom, lounge area, including snack making facilities and bathroom/toilet en-suite. The home is situated close to the centre of Netherton and has easy access to Dudley and Merry Hill shopping centre, it is well provided with access to public transport. The exterior of the building facing the road was built to simulate the residential homes in the area, with cosmetic doors fitted to enhance this impression. The main entrance to the home is off the shared car park. The home provides accommodation for mainly older people, some with a physical disability. Aids and adaptations have been provided to assist and maximise service users independence. The Home provides in-house support services of catering, housekeeping and laundry, the maintenance staff are shared with the Nursing Home. Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit was undertaken by an Inspector from the Commission for Social Care Inspection using the following information: the action plan submitted by the home to the announced inspection in undertaken during November 2005, reports from the organisation relating to the conduct of the home, the pre-inspection questionnaire, comment card responses from service users and relatives and records held at the home. The inspection involved a full tour of the bedrooms, communal rooms and service areas and provided an opportunity to speak with most of the service users. Comment cards were received from service users and relatives/visitors to the home, the results of which are included in the body of the report but were overall very positive towards the home. What the service does well: What has improved since the last inspection? Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 6 Case file documentation of service users wishes at the end of life have been addressed and more attention paid to evaluation records ensuring they are clearly identifiable to which care plan they refer. A programme of decoration is underway commencing with the small lounge and a hairdressing salon is being developed from a bathroom surplus to required numbers. Records of hot water monitoring now include details of adjustments made to each mixing valve to achieve and maintain a safe supply at service user outlets. The manager has completed the registration process. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-3 The home provides good sources of information about the home and invites prospective service users to visit and spend time at the home prior to admission to enable them to make an informed decision about entering the home. The staff group are stable well established and collectively have the knowledge and skills to assess needs and to meet these assessed needs of the current service users. EVIDENCE: The statement of purpose and service users guide have recently been the subject of review and include details of the manager and new ownership since the last inspection, these documents are an excellent source of information for current and prospective service users. Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 9 Each case file includes a contract and a letter confirming that the agreed assessed needs can be met by the home, the letter also invites prospective service users to take the opportunity to visit and trial the services offered. The case files contain a care manager assessment and an assessment by the home manager or deputy. A sample of 5 case files were randomly selected for case tracking and show that the assessment process is thorough, including all activities of daily living and an extensive range of risk assessments, assessments are subject to monthly review. The sample of case files reviewed show that the review process is limited to activities of daily living where problems have previously been identified. The reviews of the assessments do not include formal confirmation of service user or relative involvement in the process. Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 – 10 Health care needs of service users are fully met. Care plans are derived from a comprehensive range of assessments and provide the basis for the delivery of care and detail the actions required of staff to meet the identified needs. Medications are well managed all facilitating the promotion of service users health. Service users are treated with respect and their privacy upheld. EVIDENCE: A random sample of case files were selected to be inspected and case tracked. It was observed that the care plans were developed from the assessment process, were relevant and maintained to a good standard. Each file is set out in a consistent way with the assessments, care plans and evaluations at the front, followed by a range of health risk assessments and monitoring records The care plans reflect actual care requirements and the service users preferences of how it should be delivered. In speaking with service users many were able to engage in broad conversation on how care is delivered and were complementary about relationships with staff. Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 11 Service users healthcare is fully met maximising as far as practical the service users own capacity for self care. Each has a GP and other allied medical support is obtained as required, The home uses a monitored dosage system for the administration of most medications. The inspection showed that the management of medicines is robust and complies with guidelines. Medication administration is undertaken by senior carers who have completed an accredited course of training. One service user is self medicating, monitoring of medication compliance is not formal and requires to be established. The home has not received an audit by their pharmacy supplier since the change of ownership. The induction programme includes a section on treating service users with respect and their privacy is upheld with locks fitted to bedroom doors, in addition staff were observed to knock before entering and interact in a friendly and open way using the service users choice of name. Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 – 15 The home provides a well-organised and appropriately varied social and recreational activity programme that provides interest and pleasure for the service users. An open visiting policy assists service users to maintain contact with their family and friends. Service users exercise choice and control over their lives. Meals at the home are wholesome and meet the nutritional needs of service users while reflecting choice and taste. EVIDENCE: The home holds regular residents meetings where the range of activities are discussed and chosen. A diary of activities is maintained and photographs are displayed of past activities. Activities regularly undertaken include, Bingo, sing-a-longs, exercises, hand massage and nail care, games, quizzes, gardening, a group of service users enjoy knitting and others enjoy art sessions. Trips are arranged on a monthly basis. Those spoken with said there was always plenty of things happening and they felt free to participate or not as they chose. Entertainers visit on a monthly basis. Visiting clergy provide regular communion for a number of service users. Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 13 Visiting arrangements remain unchanged and service users continue to receive visitors at any reasonable time in the day and a number were observed to arrive and leave during the course of the day. Most service users receive their visitors in one of the lounges and there appears to be a good relationship between visitors and other service users. Visitors spoken with said they were very pleased with all aspects of life at the home for their relative. The case files include a section that identifies personal likes and wishes such as rising and settling time and their ability to make their own choices of clothes to wear. In conversation with service users they were content that these wishes are fully taken into account by care staff in the assistance they provide. The menus provide for a balanced and nutritious diet and is well received by the residents many able to recall the choices offered at each of the meals and that the three main meals offered a cooked option. The menus have been assessed as nutritionally sound and are put together using a high proportion of fresh produce. The kitchens were clean and all aspects of hazard analysis and critical control points were in place to provide safe food production area. The catering department recently received Dudley Gold award for healthy eating. Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The home complaints and protection policies are robust providing a safe environment in which service users feel they can voice concerns and that these will be listened and responded to. Staff demonstrate excellent knowledge and understanding of adult protection issues which contributes in providing an environment safe from abuse. EVIDENCE: The complaints procedure is readily accessible to service users and their relatives with reference in the contract and the statement of purpose which is readily available in the entrance. No complaints have been received since the previous inspection. The survey responses all indicated they new who to speak with if unhappy and wanted to make a complaint. A number of service users and relatives spoken with said they new who to speak with but had never had reason to make a complaint. The home has robust procedures for responding to any suggestion of abuse and in-house training is given in adult protection procedures. Some updating is due for staff and the manager is sourcing this through social services. Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The home provides overall a good standard of décor although some parts are becoming due for improvement, furnishings and managed services providing a safe, disabled accessible environment and an attractive, and homely place to live. The all en-suite bedrooms have bathrooms in close proximity for the convenience of service users. The home is clean, free from odours and hygienic. EVIDENCE: The Home is currently undertaking a programme of routine maintenance, renewal of the fabric and decoration of the small lounge and bathroom 17 is being adapted as a hairdressing salon. The external windows and doorframes show some signs of the beginning of paint flaking and require assessment of when to undertake a programme of external decoration. The external areas provide patio and sitting areas for service users and a small well tended garden area and shared parking. Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 16 The tour of the building confirmed that the home is maintained in a clean and hygienic condition with no evidence of malodour. The homes laundry is equipped with 2 washing machines each with sluicing and disinfection programmes. A sluice disinfector is provided. In conversation with service users using their rooms across the day they said that staff were responsive to there needs and attended promptly when called. One service user expressed concern about planned changes to the flat currently occupied but was open to discussion and had an appointment to meet with the operations director. Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 – 30 The home has a good mix of staff in sufficient numbers to provide consistency of care that meets service users needs. The home has been proactive in developing a skilled staff group with understanding of service users needs. Recruitment and selection processes are to a good standard protecting vulnerable people. EVIDENCE: An inspection of the rotas shows that the manager is supernumerary to the allocation and the deputy also has some supernumerary time to assist with training and other administrative duties. The rotas show that staff allocated are 6 in the morning, 5 in the afternoon and evening and 3 overnight, each shift being led by a senior. Currently the home has 9 care staff with NVQ qualification at level 2 or higher, 17 further are currently undertaking training. The 50 standard for NVQ trained staff has not been achieved due to problems with staff assessments, an internal appointment of an assessor is expected to remedy the problem. The manager holds the registered managers award and NVQ level 4. A random selection of staff files were inspected with the addition of the new starters and they were seen to be completed to a very good standard including Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 18 all required checks including references, CRB and POVA declaration. The company procedures are based on good practice and equal opportunities. New staff are subject to induction and foundation training to National Training Organisation specification. Mandatory training is provided for fire safety, moving and handling, basic food hygiene, and first aid. Training provided over the past twelve months in addition to mandatory courses have included Care planning and caring for residents, health and safety, COSHH, accredited medication administration, infection control diabetes awareness and effective communication. Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Leadership of this home is good and staff demonstrate an awareness of their roles and responsibilities and service users benefit from this consistency. The home regularly reviews its performance, which includes seeking the views of service users and their families. The sound financial management of the home and arrangements for safekeeping of their money safeguards service users interests personal and financial. Staff receive supervision and direction to ensure that the service users receive consistent quality care. Environment management and staff training in respect of health and safety ensures service users safety and welfare are protected. Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 20 EVIDENCE: The home is led by an experienced manager who is supported in this by a stable committed staff group at all levels. On the day of the inspection it was apparent that there was a very good atmosphere amongst the staff. The manager holds frequent staff meetings and maintains a record of these and actions taken in response to staff inputs. The home uses a range of audit tools to assess the level of quality assurance and service users views. The most recent results available were of service user and staff views undertaken by contracts monitoring and responses were overall very positive. Quarterly audits are undertaken of maintenance including the grounds, catering, housekeeping and laundry, care records, infection control, health and safety and administration. Each audit record includes an action plan. An area manager undertakes monthly unannounced regulation 26 monitoring visits. The home does not act as appointee for service users but assists some service users with their personal allowances the records of which are completed thoroughly. While all income is recorded it is recommended that the source of this income is documented. Staff supervision is well established and applied in a relevant process that covers all aspects of practice. The home has an up to date health and safety policy for safe working practice with a range of risk assessments. Staff receive training and regular updates in health and safety and fire safety. A fire risk assessment was available and this is subject to review as changes occur. Certification of a range of servicing and annual inspections undertaken of all utilities and equipment in the home are maintained and up to date. Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 21 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 22 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)(c) Requirement The registered person must ensure that the involvement of service users or their representative in the assessment process is clearly confirmed in the case file. The registered person must ensure that the reviews of the assessment process include all aspects and not restricted to previously identified problems. The registered person must ensure the pharmacy provider regularly monitors the medication arrangements at the home. The registered person must develop a programme of decoration for both internal and external areas of the home. The registered person must ensure sufficient staff are trained to NVQ level 2 to achieve and maintain a minimum of 50 qualified at all times. Timescale for action 30/06/06 2 OP3 14(2)(a) 30/06/06 3 OP9 13(2) 30/06/06 4 OP19 23(2)(d) 30/06/06 5 OP28 18(1)(c) (i) 30/09/06 Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 23 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 OP30 OP9 Good Practice Recommendations It is recommended that staff receive update training to ensure they can meet the needs of persons with obsessive-compulsive disorder. It is recommended that a documented arrangement is established to monitor medication compliance among service users who self medicate. Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Nethercrest Residential Care Home DS0000066286.V287505.R01.S.doc Version 5.1 Page 25 - 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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