Inspection on 25/04/05 for Netherlands

This inspection was carried out on 25th April 2005.

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

Netherlands 18/06/07

Netherlands 19/06/06

Netherlands 03/10/05

Netherlands 17/01/05

Netherlands 16/08/04

Netherlands 22/03/04

Netherlands 05/12/03

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Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Netherlands Spilsby Road Horncastle Lincolnshire LN9 6AL Lead Inspector Sue Hayward Unannounced 25 April 2005 at 10:00 am th 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 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. Netherlands Inspection report OP.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Netherlands Address Spilsby Road Horncastle Lincolnshire LN9 6AL 01507 522009 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Prime Life Limited Miss Valerie Evans Care Home (CRH) 11 Category(ies) of Learning Disability (LD) - 1 (one) registration, with number Learning Disability Over 65 (LD(E)) - 10 (ten) of places Netherlands Inspection report OP.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The Registered Manager is required to complete an NVQ level 4 in Care (Special Needs) Date of last inspection 17th January 2005 Brief Description of the Service: Netherlands cares for up to ten older persons and one under 65 years of age who have learning disabilities. It is a detached, two storey house situated on a main road in Horncastle. Horncastle is a small town which has a variety of facilities and services. A stair lift is available for residents who are unable to manage stairs. With the exception of one room, all bedrooms are for single occupancy and the one double room is currently being used as a single. Bedrooms are located both on the ground and first floors. Outside there is a large garden to the back and side of the property, there is also a decked area. There is car parking available to one side of the property. The home is part of Prime Life Limited. Netherlands Inspection report OP.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first of two inspections, which are required by law each year. It took place over two days. The first day was unannounced and started at 10.00 a.m. and lasted 6 hours, the second day was an arranged visit and lasted 2 hours. The main method of inspection used was “case tracking”. This involved selecting two residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. It also included discussion with two other residents individually and a group discussion. A sample of regulatory records and policies and procedures were seen and a partial tour of the premises took place. This included viewing a sample of resident’s bedrooms as well as all communal rooms. What the service does well: The home provides a comfortable, clean and homely environment for residents. The staff group know the residents well and residents said they liked the staff and could talk to them if they had a problem. Care records were very detailed and gave a clear picture of their needs and preferences. Staff were kind and courteous in their dealings with and assisted residents appropriately. Residents are free to choose whether they participate in the activities, entertainments and outings provided and these are arranged after finding out what they would like to do. Two residents said how much they had enjoyed a recent trip to “Natureland”. Netherlands Inspection report OP.doc Version 1.30 Page 6 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. Netherlands C53 C04 S2392 Netherlands V223804 250405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Netherlands C53 C04 S2392 Netherlands V223804 250405 Stage 4.doc Version 1.30 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 standard(s) 1, 2, and 3. Standard 6 does not apply as the home does not provide an intermediate care service. There are satisfactory procedures for the introduction and assessment of people to the service to ensure care needs can be met. There have been no new admissions to the home since the last inspection in January 2005. The statement of purpose and service user guide must be readily available for residents, relatives or other professionals to refer to, to inform them about the service. EVIDENCE: The statement of purpose and service user guide, which provide information about the home and service could not be located at the time of the unannounced visit. Copies of past inspection reports were on display in the hallway and a staff member said that this is where the service user guide should be. These documents were provided at the second visit and the manager said that this information is sent out to any prospective new residents. However she agreed to ensure that it is more accessible to residents, staff and visitors to the home. Netherlands C53 C04 S2392 Netherlands V223804 250405 Stage 4.doc Version 1.30 Page 9 Resident’s records included contractual information and demonstrated that the home has a thorough assessment procedure. Records demonstrated that care needs are regularly reviewed and involve residents. A staff member gave an account of the assessment process, which reflected the homes written procedure. Residents spoken to confirmed they liked living at the home and were aware that the home keeps records about them. Netherlands C53 C04 S2392 Netherlands V223804 250405 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 and 10 The care planning system in operation provides detailed information and contributes to making sure that the health and care needs of residents and their preferred lifestyles are met. This is supported by good liaison with healthcare services, medication storage and administration systems and well informed staff. EVIDENCE: Each resident has an individual plan of care. This contains detailed information relating to individual care needs. Care plans included evidence that these had been discussed and agreed with residents and two residents spoken to confirmed that they were aware that the home keeps records about them. Care records are well organised and easily available. They are reviewed on a monthly basis. Observations indicated that residents have a choice as to what they do at the home. For example on the day some residents were knitting, some were playing dominoes, one was in his bedroom listening to music and two were helping in the kitchen. Discussion with two residents indicated that they were Netherlands C53 C04 S2392 Netherlands V223804 250405 Stage 4.doc Version 1.30 Page 11 free to choose what they did and were given privacy if they wanted it. Bedroom doors are lockable if residents choose to do so. Staff had a good knowledge of the needs of residents and were aware of individual preferences and likes and dislikes. The involvement of other health professionals was well documented. There are policies and procedures in place with regard to the receipt, storage, administration and disposal of medication and staff receive training in order to carry out this task. Observation on the day of a staff member administering the lunchtime medication indicated a safe procedure is followed. Storage arrangements are satisfactory. Current residents have been assessed as requiring assistance to administer their medication. Netherlands C53 C04 S2392 Netherlands V223804 250405 Stage 4.doc Version 1.30 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 standard(s) 12, 14 and 15 The home provides a good range of activities and leisure interests both within the home and community. These are based on residents preferences who are encouraged to make choices about their preferred lifestyles and routines. The home offers a set menu, which is chosen by residents and accommodates individual preferences. Meals are well presented and nutritious. EVIDENCE: General discussion with residents and observations made during the inspection indicated that residents are able to pursue a variety of activities and leisure interests, including activities such as knitting, dominoes, card making and drawing, all of which were observed to be taking place at the time of the inspection. Residents have the choice of whether and what they participate in. The home shares the use of a minibus with another home. Once a month an outing is arranged and residents said that they were involved in decisions as to where this was to be, for example the last trip had been to “Natureland”. During general discussion residents mentioned that they also had trips to the “pub” and meals out. The manager is currently in the process of re-establishing contact with a local Church. Netherlands C53 C04 S2392 Netherlands V223804 250405 Stage 4.doc Version 1.30 Page 13 Residents made comments about the food provided such as, “I like the food” and “it’s good”. The lunchtime meal on the day of inspection was stew and vegetables, which was nicely presented, and there was a choice of fresh fruit for desert. Menus and activities are discussed at house meetings. Records seen indicated that the last one had taken place on 23.03.05. Residents are able to help out at mealtimes if they choose. Some were seen helping to lay the tables and drying pots on the day of the visit. Netherlands C53 C04 S2392 Netherlands V223804 250405 Stage 4.doc Version 1.30 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 standard(s) 16 and 18 Residents are protected by procedures in place for handling complaints and allegations of abuse. However an up to date copy of the Local Authority’s revised adult protection procedure should be obtained. Staff were clear in relation to the action to be taken should either event occur. EVIDENCE: Prime Life Limited have a Complaints procedure. This was on display on the notice board. The complaints procedure is included in the information pack that is sent out to prospective residents but staff also confirmed that the procedure is explained to residents on an on-going basis and records of house meetings indicated that residents are given opportunities to raise any issues that they may be unhappy about. Three residents spoken to also confirmed that they felt able to talk over any concerns or problems with staff. No complaints have been received by CSCI or the home since the last inspection. There is a satisfactory adult protection procedure in place however an up to date copy of the Local Authority Adult Protection procedure, which was reviewed in February 2005, had not been obtained. Staff comments indicated they were aware of correct reporting procedures and records indicated that they had completed a questionnaire relating to adult protection procedures. They also said that the procedure had been discussed at a team meeting. Netherlands C53 C04 S2392 Netherlands V223804 250405 Stage 4.doc Version 1.30 Page 15 Residents commented positively about the care and support they received from staff and felt able to talk over problems with them. Netherlands C53 C04 S2392 Netherlands V223804 250405 Stage 4.doc Version 1.30 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 standard(s) 19, 21, 22, and 26 The home is well maintained with an on-going programme of redecoration and maintenance. It provides comfortable and clean accommodation for residents who are involved in the choice of décor and furnishings of the home and are able to personalise their bedrooms as they wish. The home provides equipment to promote residents independence within the home. EVIDENCE: Residents’ comments were positive about their bedrooms and each room viewed was individually decorated and furnished and contained personal items reflecting individual interests and tastes. Residents’ confirmed that they are consulted as to choice of decor and bed linen/curtains. There is an on-going programme of redecoration and refurbishment. Staff support residents if they wish to participate in light domestic tasks around the home and the cleaning of their rooms. In addition the home employs a housekeeper in the mornings. Netherlands C53 C04 S2392 Netherlands V223804 250405 Stage 4.doc Version 1.30 Page 17 Bathrooms and toilets were clean and are lockable. There are hoists available and handrails to assist residents. The home does not currently have a sluicing facility however discussion with the manager confirmed that this matter has been referred to the organisation’s estates department and is to be addressed. Netherlands C53 C04 S2392 Netherlands V223804 250405 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 The staff group are an established team and staffing levels are sufficient to meet the current needs of residents. Staff are provided with training to ensure their competency and have the skills and experience needed to carry out their roles and are committed to the work they do. There is a satisfactory recruitment process in operation. EVIDENCE: All residents spoken to were complimentary about the care staff provide. A key worker system is in operation giving staff specific responsibilities for specific residents. All residents spoken to were aware of who their key worker was and all felt able to raise any problems with them should they arise. Discussion and records demonstrated that there are always three care staff rostered on duty in the mornings and two in the afternoons. There is one wakeful and one staff member “sleeping-in” and on-call at night. Staff work additional hours to cover any shortfalls. All staff members spoken to felt that an additional staff member in the afternoons would enable more flexibility for residents to go out however residents comments did not identify this as an issue. The matter was discussed with the manager on the second day of the inspection and it is noted that this had been raised at the staff meeting the previous day. Ways in which residents can be offered further opportunities for outings have been identified and are to be put in place. Netherlands C53 C04 S2392 Netherlands V223804 250405 Stage 4.doc Version 1.30 Page 19 The organisation have a training programme in place which includes statutory as well as more specific training to meet individual residents needs. Discussion with staff and records indicated that training is updated on a regular basis. Only two staff are currently trained to National Vocational Qualification (NVQ) level II and one is waiting to commence this. The manager and company are aware of National Minimum Standards relating to a minimum ratio of 50 trained members of staff at NVQ level II is achieved by 2005, excluding the manager. The records sampled in relation to staff recruitment demonstrated that a satisfactory procedure to protect residents is operated. No new staff have been employed since the last inspection. Netherlands C53 C04 S2392 Netherlands V223804 250405 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35, 37 and 38 The home is being led by a trained and committed manager. The environment of the home is generally safe however an issue was identified, which could put a resident at potential risk, which needs addressing. The system for accessing some statutory records needs to be reviewed in order that information is available at all times to demonstrate that the home is operating to ensure residents safety. EVIDENCE: The manager has completed the registered managers award and recently also her NVQ level IV in Care. There are systems in place where residents and staff can air their views to the manager such as staff and residents meetings. Residents knew who was in charge and one commented that she would go straight to the manager if she had a concern. Netherlands C53 C04 S2392 Netherlands V223804 250405 Stage 4.doc Version 1.30 Page 21 There are satisfactory policies and procedures including regular audits of the monies held in safe keeping by the home of residents who need this support however recent guidance that was issued by the Commission on 28.04.05 (the day after the completion of the inspection) indicates that it needs to be demonstrated how the individual resident will receive interest applicable to their individual savings. It was understood that the account used currently is a non-interest account. Risk assessments are documented in relation to health and safety issues that may arise from the environment of the home. Maintenance records are also kept. In relation to one resident who has recently changed rooms it could not be demonstrated that a risk assessment had been reviewed in relation to the possibility of the risk of burns posed from hot radiators and this is required. It is however acknowledged that the organisation are currently in the process of providing guards to those radiators identified as possible risks. The following statutory records were not available to be inspected at the time of the unannounced inspection: • • • • Records of recruitment Statement of purpose Service users guide Complaints record It is acknowledged that they were made available at the time of the second visit and the manager agreed to ensure that a system was in place for them to be available at all times. Netherlands C53 C04 S2392 Netherlands V223804 250405 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 x x x 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 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 x 3 3 x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x 3 x 2 2 Netherlands C53 C04 S2392 Netherlands V223804 250405 Stage 4.doc Version 1.30 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1& OP37 Regulation Reg. 17 2 &3 Requirement The following records must be available for inspection at all times: The statement of purpose, service users guide, records of all persons employed at the home and a record of all complaints received. It is acknowledged that these records were avaialble at the follow up visit and that the manager agreed that the system would be reviewed to ensure accessibility at all times. There must be a risk assessment undertaken in relation to the risk posed from hot surfaces to the resident who has recently moved rooms. Timescale for action June 30th 2005 2. OP38 Reg. 13 June 30th 2005 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 OP18 Good Practice Recommendations It is recommended that the home obtain the most recent copy of the Local Authority Adult Protection Procedure which was reviewed in February 2005 C53 C04 S2392 Netherlands V223804 250405 Stage 4.doc Version 1.30 Page 24 Netherlands 2. OP37 It is recommended that the arrangements for the safeguarding of residents monies are reviewed in order that they can accrue interest. (CSCI Policy & Guidance on Monies held on Service Users behalf by Corporate Appointees - issued 28/04/05). Netherlands C53 C04 S2392 Netherlands V223804 250405 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Unity House, The Point Weaver Road Off Whisby Road Lincoln, LN6 3QN 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 Netherlands C53 C04 S2392 Netherlands V223804 250405 Stage 4.doc Version 1.30 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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