CARE HOMES FOR OLDER PEOPLE
Netherhayes Netherhayes 13 Fore Street Seaton Devon EX12 2LE Lead Inspector
Vivien Stephens Key Unannounced Inspection 10:30 8 and 9th November 2006
th 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 Netherhayes DS0000045371.V312727.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. Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Netherhayes Address Netherhayes 13 Fore Street Seaton Devon EX12 2LE 01297 21646 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) carehomesllp@btconnect.com Adelaide Lodge Care Home LLP Mrs Shirley Elizabeth Fitter Care Home 28 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (28), of places Physical disability over 65 years of age (28) Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection Brief Description of the Service: Netherhayes is a large 3-storey house situated in the main shopping area of Seaton. It is close to the seafront and very convenient to all local amenities. In order to provide good security the front door is kept locked and the entrance to the home is via a pedestrian tunnel from the main shopping area. Despite the close proximity to shops and seafront the home is surprisingly quiet and the gardens tranquil with lawns, flower beds, trees and duck pond. There are some parking spaces on site, or alternatively there is a Pay and Display car park at the rear of the home. Accommodation and personal care is provided for up to 28 service users. Bedrooms are on the ground, first and second floors. The home has 2 stair lifts for those people with poor mobility. 16 rooms have en suite facilities and 1 room is a double. The home accommodates elderly people who have needs associated with old age, who may have dementia type illnesses and/or who have physical disabilities. A copy of the most recent inspection report is displayed on the notice board in the home. At the time of this inspection fees ranged between £400 and £450 per week. Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The home completed a pre-inspection questionnaire and forwarded it to the Commission several weeks before the inspection visit took place. From this information questionnaires were sent to a sample of residents, staff, relatives/visitors and professionals. Responses were received from 11 staff, 20 residents, 12 relatives/visitors, 4 care managers and 2 GP’s. The results from these helped to inform the judgements and findings of this inspection. This inspection took place over 1½ days. On the first day a tour of the home was carried out. Discussions took place with the manager, Shirley Fitter and with 6 residents and 3 families who were visiting at the time. Menus and nutrition were discussed with the cook. 4 residents were ‘case tracked’ by reading the records gathered before their admission and the care plans drawn up as a result of this information. Daily care records, medication administration, accident reports, and risk assessments were checked in relation to these 4 residents. On the second day the records of 4 staff recruited since the last inspection were checked. Staff training records were seen and interviews took place with 4 care staff. A feedback session took place at the end of the inspection with the management team. What the service does well:
Prospective new residents are given good information and opportunities to get to know the home before any decision to move in is made. The manager will normally visit the person in order to get to know them and to carry out an assessment of their needs, and to provide them with written and verbal information about the home. Visits to the home and (if possible) short stays are encouraged. Information is also gathered from relatives and health or social care professionals. One family who were visiting at the time of this inspection were particularly grateful for care and attention give to their mother to help her settle into the home. Care plans have been drawn up using all of the information gathered during the initial assessment. These are regularly reviewed to ensure they are up-todate and give good information to care staff about how each resident wants to be assisted. The care plans show how the residents are able to make choices in many aspects of their daily lives. Good care has been taken to ensure that medicines are stored and administered safely. Staff have received thorough training in the safe Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 6 administration of medicines. Storage systems are secure. Records of administration have been very well maintained. The home have kept up-to-date with good practice on the care of residents at the end of their lives. Policies and procedures are in place to ensure that residents are treated with privacy, dignity and sensitivity at the time of their death. Good training has been provided to staff on care of the dying. The home employs a part-time activities organiser. Notice boards in the home display lists of the planned activities for the coming month. These include outings, professional musical entertainments, arts and crafts, exercises and games. A new large screen television has recently been purchased along with a DVD player and the residents are planning the films they want to watch. Families and friends are always made welcome. Families who contributed towards this inspection either by completion of a questionnaire or through interview expressed complete satisfaction in the way they are kept involved and informed by the home. Much effort has been taken to ensure that meal times are a special occasion enjoyed by all of the residents. The menus have been regularly reviewed in order to ensure they are balanced and varied and are to the residents’ liking. The cook knows the residents well and knows their likes, dislikes and dietary needs. Suitable alternatives are always provided if residents do not like the main meal on offer. The dining rooms are attractive with good quality furniture and co-ordinating tablecloths, attractive cutlery and crockery that demonstrate an attention to detail. Residents can choose where they want to eat their meals, with a few choosing to eat in their own rooms. Residents spoke highly of the standard of meals provided. There are good procedures in place to ensure that concerns and complaints are taken seriously and acted upon promptly. No complaints have been received by the Commission since the last inspection. Staff have received training on the protection of vulnerable adults. The home appears comfortable, attractive and homely throughout. All areas of have been maintained to a good standard. A full-time maintenance person is employed and therefore all minor repairs are carried out promptly. Residents have single bedrooms of a good size, and many have en-suite facilities. The domestic staff have demonstrated a pride in their work by ensuring that all areas are kept clean and free from any odours. Staffing levels are generally satisfactory. A few staff suggested that the staffing levels could be improved. However, the majority of staff indicated that the staffing levels are satisfactory. Records of staff employed since the last inspection were seen. These showed that good recruitment methods have been followed. New staff have received a good level of induction and ongoing training covering all aspects of residents’ needs. Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 7 Residents, care staff, relatives and health and social care professionals praised the way the home is managed. They particularly praised Shirley Fitter for her manner and commitment. They talked about the calm and happy atmosphere, and how nothing is too much trouble for the staff, and suggested this was due to the good management of the home. The management team have demonstrated good systems to monitor the quality of the care and services provided and ensure continuous improvements. The safety of staff and residents has been given a high priority. The management team have shown over the last year how they keep up-to-date with good practice and are constantly reviewing and updating the policies and procedures. Equipment has been regularly serviced and maintained. Risk assessments have been carried out on all areas of the home and the tasks carried out. Staff have received training and updates on all health and safety topics. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 8 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 Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 9 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, 3, 4, and 5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has excellent admission and assessment procedures in place, ensuring that residents are able to make an informed choice about where they want to live. EVIDENCE: The home takes time and effort to get to know prospective new residents and their families/representatives. They have a professionally printed leaflet for initial enquiries. This leaflet has photographs and basic information about the home. There is also a comprehensive service user guide/statement of purpose providing a wide range of information about the home for new residents. Visits to the home are encouraged wherever possible, and short stays and respite care are offered where vacancies allow. The manager will visit the prospective resident to get to know them, to provide information about the home, to answer questions, and to carry out an assessment.
Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 10 Five residents were ‘case tracked’ during this inspection. Details of their initial assessments, care plans and other related information were checked. These files showed that a wide range of relevant information was gathered before the resident decided to move in, including assessments carried out by health and social care professionals. The manager, Shirley Fitter, explained the process she follows when assessing prospective new residents, and how she takes care to ensure that the home is able to meet their needs before agreeing to admit them. She said she also encourages them to visit other homes in order that they can be entirely certain that Netherhayes is the right home for them. During the inspection residents and visitors talked about how they chose Netherhayes. They talked about the information they were given, and how they visited other homes before choosing Netherhayes. They were all very satisfied with their choice. One resident said “I never realised how happy I could be until I moved here!” One family talked about the way their mother had been welcomed into the home, and how the manager and staff had relieved the stress and worry of giving up her home through the care and attention given to the whole family throughout that time. This had helped their mother settle quickly. The home does not provide intermediate care. Netherhayes DS0000045371.V312727.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate a very good understanding of the health and personal care needs of residents through good care planning systems. Residents are safeguarded by good methods of administration and recording of medicines, although some minor recommendations have been made to ensure even greater safety. Residents are treated with dignity and their privacy is respected. Residents can be assured that all of their health, social and emotional needs will be met at the time of their death. Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 12 EVIDENCE: Four care plans seen during the inspection contained comprehensive information covering all aspects of the residents’ needs. The plans showed how the home considered the goals they hoped to achieve when assisting residents to maintain or regain independence. Records showed that the plans have been reviewed at least once a month. The documents are stored in files that also contain the daily reports completed by the care staff. This ensures that staff have daily access to the care plans and can refer to them when writing the daily reports to check that all required tasks have been carried out. Moving and handling risk assessments are stored discretely in residents’ bedrooms along with a brief summary of the care tasks to be carried out. These were discussed with the manager, Shirley Fitter and suggestions were made for ways of increasing the level of detail, for example, with explanations of how the resident wants to be assisted when they have a bath. The care plans include information about health care needs, including diabetes and Parkinson’s disease. Two GP’s responded to this inspection by completing questionnaires, and their responses showed that they are satisfied with the care provided by the home. The home has two specialist nursing beds. Nutritional screening is carried out where necessary, weight is monitored regularly, and assessments are carried out to ensure pressure sores are prevented. Staff have received a range of training on health topics including diabetes, mental health, dementia, continence, and skin care. Future training plans include training on Parkinson’s disease. The home uses a monitored dosage system provided by a local pharmacy. These are stored in a locked medicine trolley and this in turn is stored in a locked cupboard when not in use, ensuring complete safety. At the time of this inspection no controlled drugs had been prescribed. Secure storage and correct recording systems are in place for such times as when controlled drugs are used. A medicines refrigerator is provided to ensure any medicines that need to be kept cool are stored safely and at the correct temperature. Good recording systems are in place, and records seen during the inspection showed that these have been maintained carefully. Those care staff who administer medicines have received thorough training to the recommended level. Care staff have not kept a record of when prescribed creams have been applied – this is recommended. It was also recommended that care plans set out how, why, where and when these creams should be applied. It is also recommended that where residents administer their own medications a record is maintained of when, and how many, medicines are handed over. The home has taken every care to ensure residents are given the best possible care at the end of their lives. They have copies of current good practice
Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 13 guidance issued by the Department of Health and other recent good practice literature. Their own policies and procedures have been carefully reviewed in line with this guidance. Staff have received recent up-to-date training on care of the dying. There were good examples of how privacy and dignity are maintained. Staff were seen knocking on doors before entering. Residents are accommodated in single rooms, and personal care tasks are carried out in the privacy of their rooms. The hairdressing room has recently been adapted and now doubles as a medical treatment room where residents can choose to receive treatment by the District Nurses or GP’s if they prefer, or they can receive treatment in their bedrooms if they prefer. Residents are addressed by their preferred names. Netherhayes DS0000045371.V312727.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 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents can choose from a very good range of activities suitable for most interests and abilities. Residents’ families and friends are encouraged to visit whenever they want and to be fully involved in the care of their loved-ones. Residents are enabled to have choice over all aspects of their daily lives. Residents receive well-balanced and nutritious meals to suit individual tastes and dietary needs. EVIDENCE: There is a good range of activities provided to suit most interests. A calendar of forthcoming outings, entertainments and activities is displayed in the home each month. Planned activities during October included professional musicians, an outing to Weymouth, Thanksgiving Service, exercises, and
Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 15 coffee at the local Age Concern. The home employs an Activities Organiser two afternoons each week, and additional care staff are employed 2 or 3 mornings each week to take residents out. Residents’ meetings are held monthly, and during these meetings the residents are consulted over various aspects of daily life at the home including activities and menus. One of the relatives commented “Very pleased with the excellent care provided and the friendliness of staff to myself and other visitors, and more importantly to the residents. They give them their time (playing games, chatting etc).” Residents said that there are activities they can join in if they want, but this is entirely their choice Their comments included, “There are activities but I don’t join in. I’m not a’ people person’.” and “I particularly enjoy the weekly singing activities.” A large flat screen television has recently been provided in the main lounge. This has been purchased using money raised through fundraising activities. The television was chosen by the residents, and it is large enough for everyone to see clearly. A DVD player has also been purchased and residents are planning to watch some of their favourite films. The manager and staff talked about how residents make choices over all aspects of their daily lives, from the time they want to get up, what they want to wear, and what they want to do. Residents said they have just as much freedom as they had when living in their own homes. Three families were visiting at the time of this inspection. They all confirmed that they are always welcomed whenever they visit, and are kept fully involved in the home and the care of their loved-ones. They praised the home highly for the care provided. Comments from relatives who completed questionnaires prior to this inspection included “I consider that my mother is very fortunate to be a resident at Netherhayes where she gets a good quality of life through the constant care by dedicated staff, together with good food. She is always clean and tidy and is as happy as she can be in her current mental state. I have nothing but praise for Netherhayes and all their staff” and “I have always been able to sort out any matters of concern about my husband at Netherhayes with the person in charge at the time”. The menus were discussed with the cook. She knows each of the residents well and knows their likes, dislikes and dietary needs. The menus are varied and balanced and alternatives are always provided if residents don’t like the main meals on offer. The dining tables have been attractively laid with pretty tablecloths and table decorations demonstrating the way the home endeavours to make mealtimes a pleasurable occasion. One of the care managers who completed a questionnaire prior to this inspection said “This home is not afraid to ask for advice and I feel listen and take on board any suggestions made. I have always been happy to place in this home. I have always found staff welcoming and the manager co-operative. Residents always appear happy and
Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 16 well cared-for, certainly I saw marked changes in a client I moved from another home – appetite improved, gained weight…” Netherhayes DS0000045371.V312727.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assured they will be listened to and their concerns and complaints acted upon. Good measures have been put in place to protect residents from abuse. EVIDENCE: No complaints have been received by the Commission since the last inspection. Most of the residents who responded to this inspection by completing a questionnaire said they always or usually know who to talk to if they aren’t happy, or if they want to make a complaint. The home’s complaints procedure is displayed in the hallway, and is also set out in the Statement of Purpose/Service Users’ Guide given to all residents on admission. A record of complaints is maintained by the home – no complaints have been recorded since the last inspection. It was suggested that informal grumbles and complaints are recorded to enable the home to demonstrate how even the minor issues are taken seriously and addressed. The home has a range of policies and procedures in place relating to the prevention of abuse. All staff have had training on the protection of vulnerable adults. All staff who responded to this inspection said they understood the procedures if an allegation of abuse is made.
Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 18 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, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable, safe, clean and attractive environment. EVIDENCE: The home has been well maintained both internally and externally. A maintenance person is employed who ensures that all regular maintenance tasks are carried out promptly and that all areas are safe and in good order. A tour of the home took place that included approximately half of the bedrooms, all of the communal areas, toilets, bathrooms, the kitchen, laundry and garden. All areas of the home have been decorated and furnished to a high standard and appeared comfortable and homely. The domestic staff have taken a pride in their work, ensuring that all areas of the home are kept clean
Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 19 and fresh at all times. This was confirmed by all of the residents who responded to this inspection by completion of a questionnaire. All bedrooms are of a good size and have been individually furnished and decorated to a good standard. Finishing touches include attractive bedspreads and co-ordinating curtains and good quality carpets. Residents are encouraged to bring furniture and personal effects in order to make their rooms feel homely. Where couples are accommodated the home offers two bedrooms that can be used flexibly to provide a bedroom and private lounge, or two single rooms according to the preferences of the couple. A relative commented “My aunt has been at Netherhayes for one year. I have found her to be very happy there. The staff are very helpful, the rooms are good with nice outlook, she has some of her own bits and pieces which makes it more like home.” Most radiators have been covered to prevent the risk of burns in all bedrooms. A few remaining uncovered radiators are planned to be covered in the near future. Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 20 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. Residents benefit from sufficient well trained staff to meet their needs safely and consistently. Residents are protected from potential abuse through good recruitment practices. EVIDENCE: On the first day of this inspection there were 3 care workers on duty in the morning plus the manager and the Senior Care Assistant. An additional care worker is employed between 8 am and 11am to provide extra cover during the busy part of the morning. There was also a cook, 2 cleaning staff and 1 kitchen assistant. The home employs a full time maintenance person, a part time activities organiser, and extra care staff are employed 2 or 3 mornings a week to take residents out into the town. Four of the staff who responded to this inspection by completing a questionnaire said they would like to have more staff cover in order to provide more ‘one-to-one’ time with residents. This was discussed with the staff on duty at the time of this inspection. They said that staffing levels have been
Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 21 increased in recent months and are now reasonably good. The times when they are busy are mainly when a member of staff has unexpectedly gone off sick and when a replacement cannot be found at short notice. They said that wherever possible the manager will try to find someone to cover in these situations. Residents and visitors who were interviewed during this inspection also said they were generally happy with the level of staff employed. The files of four staff recruited since the last inspection were seen. These contained application forms, at least two satisfactory references, and home office permits where applicable. Criminal Records Bureau checks have been carried out, although in some cases these were received after the staff had been confirmed in post. This was discussed with the management team, who confirmed that they had misunderstood the rules about the ‘portability’ of these checks from one employment to another (they had seen copies of checks carried out by the last employers). They had recently realised their procedures were incorrect and have taken action to ensure that, in future, all staff have a Criminal Records Check and Protection of Vulnerable Adults check carried out by Netherhayes before the staff are confirmed in post. All new staff have received a good level of induction training. Since the last inspection the level of qualified care staff has increased. More than 50 of care staff now hold a nationally recognised qualification. A training matrix on the office wall shows at-a-glance the training staff have received and when updates are due. The home now provides a very good level of training in all health and safety topics as well as a wide range of subjects relevant to the care needs of the residents. Subjects covered have included – Care for the dying and bereaved, skin care, continence, elder abuse, diabetes, mental health, sip feed workshop, communication problems/activities for wellbeing, and dementia. Records show that staff have received supervision every six weeks and are appraised formally once a year. This enables the home to address any practice and training issues on a regular basis. Several comments were made by both staff and residents about the positive effect on the home that the staff who have been recruited from overseas has made. There is a cultural balance within the home that is enjoyed and appreciated by all. Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 22 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, 33, 35, 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well managed. Comprehensive systems are in place to ensure the quality of the facilities and services are constantly monitored and improved where necessary. Residents’ finances are safeguarded by good procedures. Good systems and training are in place to ensure the safety of residents, staff and visitors. Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 23 EVIDENCE: The home is managed by Shirley Fitter. She has many years of relevant experience, and holds a National Vocational Qualification to level 4 and also the Registered Managers’ Award (these are recommended qualifications for managers of care services). Both the Managing Director and Director of Care also hold these qualifications. There were many positive comments about the way the home is managed, and particular praise for Shirley Fitter. Comments from care staff included, “Mrs Fitter has always said to us that if we have any concerns about the residents or other members of staff however small that she has an open door policy and to please come and speak to her about it.” The home has an excellent range of methods of checking the quality of the service they provide. Residents’ meetings are held regularly, and questionnaires are sent to residents and relatives and the results collated. The home has a regular newsletter where the results of the questionnaires are published. There is a monthly Management Review where every aspect of the home is covered. These provide evidence of an exceptionally high level of checking, monitoring and improvement. The minutes of these meetings are forwarded to the Commission. Records of cash held on behalf of residents were checked. Residents are encouraged to handle their own financial affairs, with assistance from their family or representatives if required. Very small amounts of cash are held on behalf of a few residents who are unable or unwilling to hold cash themselves (this money is for incidentals and extras). Regular expenses such as hairdressing are paid for by the home, and the resident or their relative/representative are invoiced once a month. The records and cash were checked and found to be entirely satisfactory. The home has comprehensive policies and procedures in place. These are regularly updated and professional opinion is sought to ensure they meet with current good practice. Records seen during the inspection showed that all equipment has been maintained and checked regularly to ensure safety. Risk assessments have been carried out on the environment. Actions to reduce or eliminate the risks have been identified where necessary. Moving and handling risk assessments can be found in residents’ bedrooms. Policies and procedures are in place covering all aspects of health and safety. Staff have received training and updates on all health and safety related topics. Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 24 Records seen during the inspection included the fire log book and accident book. These have been completed satisfactorily and demonstrated safe systems in place. Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 25 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 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X x 2 4 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 4 X 3 X 3 X x 3 Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations Where prescribed creams or lotions are applied by care staff a record should be kept of their administration. Care plans should explain how, why, where and when these creams should be applied. It is also recommended that where residents administer their own medications a record is maintained of when, and how many, medicines are handed over. The programme of covering radiators to be continued in order to eliminate the risk of burns and scalds. 2 OP25 Netherhayes DS0000045371.V312727.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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
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