Inspection on 03/08/06 for Netherfields Rest Home

This inspection was carried out on 3rd August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Netherfields Rest Home 17/19 Roe Lane Southport Merseyside PR9 9EB Lead Inspector Elaine Stoddart Unannounced Inspection 09:00 3 and 8th August 2006 rd 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 Netherfields Rest Home DS0000067616.V306538.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. Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Netherfields Rest Home Address 17/19 Roe Lane Southport Merseyside PR9 9EB 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) 01704 54 1034 0870 76288881 Ramos Healthcare Limited Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 22nd March 2006 Date of last inspection Brief Description of the Service: Netherfield Residential Care home is registered to provide personal care and accommodation for up to 27 older persons. 22 were resident at the time of the inspection. The home does not provide nursing care. This is provided in conjunction with the district nursing services when required. The home is owned by Ramos Health Care and managed by Annette Worrell, who is yet to apply to the Commission for Social Care Inspection for registration (CSCI). The home is situated on Roe Lane in Southport and is reasonably close to the town centre and all the amenities it provides. These include theatre, pubs, restaurants and parks. There are shops and access to public transport close by. The home is located in two buildings, which have been converted and joined centrally. Accommodation is located on three floors with a stair lift and passenger lift giving access to the upper floors. There are two lounges and a dining area giving ample communal space for the residents. There is a large rear garden with seating for the residents and also a sitting area at the front of the building. Disabled access is available to the exterior. The current rate of charges is £355.50 - £370.00 per week. Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days. It was an unannounced visit and conducted as part of the regulatory requirement for care homes to be inspected at least twice a year. The site visit also consisted of a complaint investigation. The findings and action to be taken by the provider are being addressed through the complaint procedure. A tour of the building was conducted. A selection of care staff and home records were also viewed. During the inspection 3 residents were case tracked (their care files were examined and their views of the home were obtained). This process was not carried out to the detriment of other residents who also took part in the inspection process. The manager, 5 staff members, 6 of the 22 residents. A collective group of residents, 2 relatives and 1 visitor were spoken with and their views obtained of the home. Survey forms ‘Have your say about….’ were also given to residents to complete. Comments received from the surveys and discussions, which took place, are incorporated within this inspection report. What the service does well: Some residents spoke positively about the service provided and said, “I have been here for two years and the staff are all very nice” “The staff are all lovely” “The staff are always there when I need them” A number of staff have been employed at the home for many years and are very committed to caring for the residents. Staff spoken to said, “I love it here”, “We have a good staff group”. Relatives and visitors are made welcome and this was observed during the inspection as visitors popped in and chatted freely with the staff and residents. One visitor said, “They have helped my friend settle in very well”. Staff training is ongoing and statutory training is kept up to date. Over 50 of the staff employed are qualified in National Vocational Qualifications (NVQ) Level 2. Staff have recently received an update in medication. Care staff receive a verbal report at the beginning of each shift and are quick to report any changes that affect the well being of the residents. The manager and /or Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 6 deputy manager assess all prospective residents and a plan of care is then written after admission. Care plans are in place for all residents and access is available to health care professionals. What has improved since the last inspection? What they could do better: There are still outstanding requirements from the last inspection and these are highlighted with thin the requirements section of this report with time scales for action. Some surveys received from residents made particular reference to the food provided and comments include – “There are no alternatives offered” “There is no choice of meals” “Deserts for diabetics could be catered for in a more varied way”. In view of the comments made the home should survey residents to obtain their ‘likes and dislikes’ and to obtain their views on the food and menus in place. A residents meeting was held at the time of the inspection to discuss meals and action agreed to be taken by the staff. As a result of the complaint investigation the home was recommended to provide a daily menu with alternatives for lunch and tea and to cater for special diets i.e. diabetes. Staff should receive diabetic training to enable them to meet the needs a number of residents who have diabetic needs. The home employs 1 cook weekdays and the care staff cover the weekends. A recommendation is made to employ a Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 7 cook at the weekend to relieve staff of this duty. The statement of purpose makes reference to 3 cooks/chefs employed. During the inspection a number of environmental, repairs and improvements were noted and these are included within the requirements and recommendations of this report. A number of fire doors were noted to be wedge open and this was brought to the attention of the manager to rectify. Information must be sought from the fire service regarding fire safety precautions should this continue. Where two residents occupy a double room a screen facility should be made available for the privacy and dignity of the residents. Unless a record is made that this is not the residents choice. The home must provide sufficient hoist equipment to meet the needs of the residents. Staff spoken to commented there is “not enough to enable us to carry out our role and residents often have to wait”. 4 residents accommodated require hoist equipment. Formal staff supervision must be provided. Recruitment procedures are not robust to protect the residents. Clearance from the Protection of Vulnerable Adults (POVA) register, which is a requirement prior to employment in order to protect residents from known abusers, had not been obtained for 2 staff members. This has been raised as a requirement at the last inspection and must be addressed with urgency. A review of the home’s recruitment practice would be beneficial. The staff should be informed of the new ‘Safeguarding Adults’ policy in place for Liverpool and Sefton Social Services. Staff administering medication have received training, however a number of errors in the administration of the recording systems were found during the inspection and brought to the attention of the manager. Strong recommendations are made within the recommendations of this report to improve this. Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 8 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. Netherfields Rest Home DS0000067616.V306538.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 Netherfields Rest Home DS0000067616.V306538.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6. The quality in this outcome area is good. This judgement has been made using available evidence, including the complaint investigation and visit to this service. Residents are provided with the information they require to make an informed choice about living in the home. Full assessments of need are conducted prior to admission to ensure that the home can meet their needs. EVIDENCE: Standard 6 Intermediate Care is not provided at the home. The home has recently been taken over by new owners who have produced a new statement of purpose and service user guide outlining the service provided. The manager and/or senior care staff undertake an assessment for all potential residents. Assessments for three residents were viewed and contained sufficient detail with regard to personal/social information, general past medical history, medication and current health care needs. A new assessment process is contained within the statement of purpose introduced by the new owners and all new residents are to be admitted using this format, which should include the maintaining of weight records for each individual. This is highlighted within the recommendations of this report. Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 11 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): 7,8,9,10. The quality in this outcome area is good. This judgement has been made using available evidence, the complaint investigation and visit to this service. Resident care plans reflect current health care needs and the actions that are required by the staff to meet those needs. Medications practice should be improved to protect the welfare of residents. EVIDENCE: The care files of 3 residents were viewed. Residents have an individual care file and the plan of care is based on the initial assessment.3 residents care files were viewed. The care plans evidence the daily activities of living with reference to diet, mobility, personal hygiene, continence and social background. Care plans are generally reviewed monthly to reflect any change in the condition of the resident and any change in treatment or medication. The manager should make reference to changes in the care plans and update all care plans in the same format i.e. needs/action/outcomes. A new format of assessment and care plan details is outlined in the new statement of purpose all files are to be updated using this process. General risk assessments Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 12 including manual handling instruction are in place for those are at risk of falling or who require assistance with their mobility and are reviewed regularly. Risk assessments must be in place to assess safe use of the stair lift and this requirement is outstanding from the last inspection. Care files viewed evidenced visits by GPs and district nurses. 1 resident had been recently reassessed by their GP at the request of the manager to review her medication. The care needs of 1 resident was discussed with the manager and more detailed information was requested to demonstrate the care provided in view of the regular monitoring by the care staff, i.e. food and liquid intake and mobility. Weight records should also be recorded to monitor weight loss/gain of all residents. (Outlined in the new assessment format in the statement of purpose). In view of the comments from resident’s surveys the home should review those residents with diabetes to enable them to meet their dietary needs. Diabetic training is also recommended to raise staff awareness of this condition. A number of areas in need of improvement regarding medication were identified during the inspection. These include - written records on the MAR (Medicine Administration Records) should be countersigned, all administrations should be recorded, a photo of each resident on file to confirm identity, controlled drugs book should record all administrations and balance, with no gaps in records. Two staff should sign controlled drug record. These are strongly recommended in the main inspection report. Residents are requested to sign an agreement for self medication and this was confirmed on care files and discussion with one resident who self medicates. The MAR sheets evidenced gaps in staff signatures following administration of medication. There are records of the date for medication received and returned in place. The medicine cupboard is kept securely locked. The staff have had recent medication training and a review of this should take place in view of the recommendations made. Residents gave examples of how staff treat them with dignity and respect, “The staff are very polite and help me with my personal care”, “The staff are lovely”. Staff were observed during the day to speak to residents in an appropriate manner and always knocked prior to entering their room. One relative commented that her mother was wearing another residents dress “although it is very nice it is not hers”, no complaint was made as this was acted upon immediately by the manager who informed the staff on duty. Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15 The quality in this outcome area is good. This judgement has been made using available evidence, the complaint investigation and visit to this service. The home is able to demonstrate that residents are encouraged to be independent and have a choice regarding how they wish to spend their day. Their rights are respected. EVIDENCE: The home presented with a warm, relaxed and pleasant atmosphere and visitors were made welcome and were observed to ‘pop in’ during the visit. Residents confirmed that they enjoy the social activities that are arranged ‘in house’. The home offers art classes, puzzles, connect 4, dominoes, film shows on a big screen, bingo, flower arranging and are displayed on activity programme . The hairdresser attends weekly. Religious groups are held in the lounge. Residents surveys “Have your say…..” received said – “There are not enough activities and the staff are so busy the bingo is often cancelled” “I enjoy the groups which are held in the small lounge” Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 14 The routine in the home was observed as being based around the needs and wishes of the residents and a resident said, “I like to all my meals in my room”. Discussion with some residents and staff confirmed that choices are available and although the menus don’t state an alternative it says on the menu ‘alternatives are always available on request and fresh fruit is always available’. Also states ‘a variation might occur from time to time because of seasonal change and availabilty’. The cook sees residents to obtain their ‘choice or alternative’ of the day and records their alternative in a tea time menu’ record book for each resident. Some surveys completed showed that some residents are satisfied with the food, “The cook is very versatile with her menus”, “The food is very good”, while others stated there is “no choice” and menus “are often changed”. The home should provide the residents with 4 weekly menus/and alternatives for them to choose from. Diabetic training for staff is also recommended as surveys completed highlighted the need of staff to meet their dietry requirements. Lunch was served in the dining room by the care staff. The dining room tables were attractively laid. The home offers three meals a day with tea and biscuits at various other times. The cook is not available on Saturday and Sunday and the care staff at the home provide the weekend meals. A residents meeting of 8 was being held at the time of the visit and menus’ were discussed. A food survey is recommended for the home to consult all residents on the food provided. Recommendations were made as a result of the complaint investigation for the home to provide menu’s with alternatives for the residents. Staff were seen to be supportive to the needs of the residents and were cheerful and warm in their approach. Residents confirmed that their visitors are made welcome at any time. Residents are encouraged to manage their own finances and staff only deal with pocket monies and payment for hairdressing. Financial records were viewed, these evidenced details of recent financial transactions. Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 15 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 quality in this outcome area is adequate. This judgement has been made using available evidence, including the complaint investigation and visit to this service. Residents are aware of how to make a complaint. Abuse policies and procedures are in place to protect the residents. EVIDENCE: How to make a complaint is contained in the Service User Guide, which has been produced by the new owners and is available to all residents. Residents spoken to confirmed they are aware of how to complain. A resident said, “I am able to speak for myself”. The inspection consisted of a complaints investigation and the results of this The home has the latest Sefton guide for protection of vulnerable adults however staff are not familiar with this latest document and this should be circulated to staff.The manager confirmed that this is to be circulated to staff. Discussion with staff confirmed their awareness of the whistle blowing/abuse policy. An advocacy service is available to contact and the service is displayed on the notice board. Policies ansd procedures are in place and are reviewed annually by Mentor services. The recruitment of staff is outlined within the staffing section of this report. Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 16 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): 19,20,21,22,23,24,25,26. The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents live in pleasant, safe, comfortable and well-maintained surroundings. EVIDENCE: A partial tour of the building evidenced a clean, comfortable home. Residents interviewed said that their rooms are clean and tidy, however some comments were received from residents surveys - “The toilet and basin clean but they don’t always dust”. Others commented “I love my room”, “I have everything I need”. Several bedrooms were viewed and these were furnished to individual taste and residents had brought in personal items e.g. electrical equipment, pictures and ornaments. Bathrooms were equipped with aids to help residents who are less independent. The lounges seated small groups of people. The gardens had recently been tidied up and mown. There is a ramp to the main Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 17 front door and a portable ramp to the front 2 steps, and residents have the use of a passenger lift and a stair lift. A number of repairs and decoration required was noted and brought to the attention of the manager. These inlude – new carpets in a number of rooms, (especially room 11, which is rucked and soiled), small lounge carpet fraying needs replacement. Discussion with the manager confirmed that groundfloor carpets are due to be replaced and these areas have been measured up. (Not all private rooms are included). Repair is required to the grab rail at bottom staircase were stair lift is situated. Fire doors must not be propped open and the manager advised of this at the visit. Radiator covers are fitted in some areas, ensure risk assessments are in place were there are no covers. The new owners are making progress to improve the environment and have undertaken some improvements ie decoration of rooms, new flooring in room 14 and a proposed ramp at rear. The laundry facilities are located in the basement and require hand washing facilities and soiled washing to be separated from the clean. The home should avoid lost laundry (As expressed by 1 relative at the time of the visit and comments from surveys received). The home has a maintenance man to respond to any repairs required. 3 domestic assistant’s are employed to clean the home , however the manager confirmed that due to shortage of staff they have been covering as care staff. Records are kept of hot water sinks and shower rooms. Hoist equipment is used at present, however only one is available and this is required by 4 Service Users and results in them waiting for the service. Emergency lighting is provided throughout the building and subject to a full maintenance contract, however last record of check 4/5/06 and is required monthly. Residents have the use of a call system with alarm facility in their bedrooms and staff were observed answering calls for assistance. A screen is required in the double room 11 for privacy of the residents accomodated.There are plenty of clean bedding and towels available. Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 18 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): 27,28,29,30. The quality in this outcome area is adequate. This judgement has been made using available evidence, complaint investigation and a visit to this service. There are sufficient numbers of appropriately trained and experienced of staff care for the residents however recruitment practices are not robust to protect their welfare. EVIDENCE: The staff rotas viewed evidenced the number of staff on duty, which wasa normally 1 senior/manager, 2 carers, 1 kitchen assistant,1 domestic, 1 handyman and 1 cook. An extra member of staff who lives in a flat at the home is available for cover if required in emergencies. The manager is presently recruiting additional staff as the domestic staff are currently covering as care staff due to sickness a holidays to provide continuity and avoid the use of agency staff. The complaint investigation identified staff shortages occaisionally occur and the home has been required to address this within the outcome of the complaint findings. Positive coments were received from some residents interveiwed – “I have been here for two years and the staff are all very nice”. “They are always there when I need them”. Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 19 Other comments obtained fron the surveys received – “Staff are often staff too busy”. “I sometimes have to wait a while for them to come” The staff files of 3 staff were seen and 2 employees had commenced employment prior to a POVA (Protection of Vulnerable Adults) check or CRB being received. One staff file only evidenced this information. This was raised as a requirement at the last inspection in March 2006 and this continues to put residents at risk. Two written references are also required prior to employment and these were not in place for all staff employed. Recruitment practise must be robust to protect the residents. The training records evidenced staff training in the last six months, which included Health & Safety, Fire Safety, Manual Handling, Medication and Food Hygiene. The new owners are to develop atraining plan to demonstrate training needs. 15 care staff are employed and 50 are qualified in NVQ level 2 or are working towards it. There was no evidence of induction records on the staff files seen. Training in diebetic needs has been recommended. Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 20 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. The quality in this outcome area is adequate. This judgement has been made using available evidence, complaint investigation and a visit to this service. The home employs a manager who is yet to be approved by CSCI. Formal supervision of staff is not in place. Staff are trained in safe working practices and certificates for services are up to date. The residents are consulted regarding the running of the home. EVIDENCE: The home has recently been taken ower by new owners. The home employs a full time manager who has not yet been approved by the CSCI. The manager is taking a NVQ Level 4 qualification and is settling in to her new role.The manager is supported by the owner who visits the home weekly. Annual satisfaction questionnaires are completed regarding the care and facilities at the home and a recent quality assesment on star rating was being conducted Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 21 at the time of the inspection. Minutes of the most recent staff were available held July 2006 a future meeting is planned for August to keep staff up to date. Financial policies and procedures are in place and reciepts obtained. Mentor supplies all the home’s policies and procedures and reviews them annually. A number of certificates in safe working practice areas and equipment were examined. These were current for fire safety, lift, gas, electrics. PAT. Regular water temperature checks are conducted and recorded. Staff supervision is yet to be organised by the new manager and supplied every 6-8 weeks. Discussion with a number of staff took place to obtain views on the new ownership and management of the home. Comments include – We need regular staff meetings, supervision and appraisals to keep us up to date” “I love it here. We have a good staff group” “There is not enough time to socialise with the residents” “We need the equipment to do the job. There arent enough hoists”. Residents and a visitor interviewed supplied the following comments on the management of the home – “The home is very well run” (visitor) “There has been no difference since the new owners took over. The staff are all very good” (Resident) A pleasant atmosphere was evident and the staff are consistent with very few few staff changes.However the manager is presently recruiting new staff to increase the staffing levels. Discussion with residents confirmed their satisfaction with the care and support provided and the pleasant attitude of the staff. A recent residents meeting had taken place to obtain their views on the new ownership. Staff training is up to date and the owner is to produce a training plan for all statutory training and others areas identified as a result of the recent complaint, ie diebetes. All accidents and injuries are recorded. A number of fire doors were noted to be wedged open and this was brought to the attention of the manager during the visit and advice recommended to be sought from the fire service on this. The laundry facilities should include handwashing facilities to avoid crioss infection and foul and clean linen should be separated. Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 22 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 23 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 OP22 Regulation 13 Requirement The manager shall ensure that stair lift risk assessments are in place for residents using this facility. (Time scale not met at last inspection) The manager must ensure that a satisfactory Criminal Record Bureau (CRB) check is obtained prior to employment for all new staff. (Time scale not met) The manager must ensure that care staff employed obtain formal supervision. The manager shall ensure that the correct recruitment and selection procedures are followed. (As outlined in Standard 29 and Regulation 19 and Schedule 2) of the Care Standards Act 2000. The manager must ensure that there is sufficient hoist equipment in place to meet the meet the assessed needs of the residents. New carpet in room 11, repair grab rail on staircase next to stair lift. Replace carpets in DS0000067616.V306538.R01.S.doc Timescale for action 30/09/06 2 OP29 19 30/09/06 3 OP36 18 30/09/06 4 OP29 19 30/09/06 5 OP22 23 30/09/06 6 OP19 23 31/12/06 Netherfields Rest Home Version 5.2 Page 24 ground floor corridors due to wear and tear. 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 3 Refer to Standard OP27 OP7 OP24 The home should provide a screen for use in double rooms occupied by 2 residents, unless a record is made of their choice not to have this facility. Written records on the MAR (Medicine Administration Records) should be countersigned, all administrations should be recorded, a photo of each resident on file to confirm identity, controlled drugs book should record all administrations and balance, with no gaps in records. Two staff should sign controlled drug record. Diabetic training should be provided for staff. Review residents with diabetic needs. The home should conduct a survey of the residents regarding meals and menus. Review care plans in line with assessment and care planning documentation outlined in the new Statement Of Purpose. The home should review the care needs of one resident who is receiving a high level of care and improve the recording systems in pace to demonstrate the care provided. The home should conduct monthly emergency lighting checks. The home should consult with the fire service regarding the wedging open of fire doors. Good Practice Recommendations The home should employ a weekend cook. The home should maintain weight records for residents. 4 OP9 5 6 7 8 OP30 OP15 OP7 OP7 9 10 OP38 OP38 Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 25 11 OP26 The home should provide hand-washing facilities in the laundry and separate soiled and clean linen. Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Netherfields Rest Home DS0000067616.V306538.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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