Inspection on 07/02/08 for Nethermoor House

This inspection was carried out on 7th February 2008.

CSCI found this care home to be providing an Adequate service.

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

Nethermoor House 10/02/09

Similar services:

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

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

CARE HOMES FOR OLDER PEOPLE Nethermoor House 131 Chaseley Road Etching Hill Rugeley Staffordshire WS15 2LQ Lead Inspector Irene Wilkes Key Unannounced Inspection 7th February 2008 10:00 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 Nethermoor House DS0000069415.V358900.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. Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nethermoor House Address 131 Chaseley Road Etching Hill Rugeley Staffordshire WS15 2LQ 01889 584 368 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) Nethermoor House Care Ltd Mrs Valerie Joan Hollins Care Home 19 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (19) of places Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category (OP) 19 Dementia over 65 years of age (DE)(E) 6 The maximum number of service users to be accommodated is 19. The two single rooms identified as being not fit for purpose, due to their small size, continue to be used only as long as the Service Users currently in occupation in these rooms remain there. 2. 3. Date of last inspection Brief Description of the Service: Nethermoor is located on the periphery of the town of Rugeley and the home overlooks part of Cannock Chase. Over the years the home has been extended to provide more resident accommodation. The original part of the home maintains a number of original features. The house is located within its own extensive grounds. There are no facilities in the immediate area that residents can walk to or use. The home is registered to offer accommodation to 19 older people, six of whom may have dementia. There is a large lounge adjoining the dining room, with another smaller quiet lounge, all on the ground floor. The communal areas are pleasant with a homely feel. There are single bedrooms on the ground floor, and a mixture of double and single upstairs. Some of the double rooms are being used as singles to allow more privacy for more residents. The first floor can be accessed via the shaft lift or stairs. Bathing and toilet facilities are located throughout the home. Nethermoor does not provide en-suite facilities. The parking space at the front of the home is laid to gravel. This is not easy for an older person to negotiate. The home has an extensive enclosed garden area at the rear with raised flowerbeds, with the remaining area being well-maintained lawns. The Service User Guide did not contain information about the fees charged by the home. Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was a key unannounced inspection. This means that all of the national minimum standards that the commission for social care inspection consider most greatly affect the health, safety and welfare of the residents were looked at. The inspection took place over approximately a 9 hour period. 18 residents were at home during the visit. A number of residents were asked their views of the home. A senior care worker assisted with the inspection throughout the day. Other care staff were on duty at different times. The cook, who is also a senior care worker, was also on duty. Staff contributed to the inspection process. The inspection included examining a sample of 4 residents’ files and a sample of health and safety documentation including maintenance records and the records relating to fire safety. The arrangements for administering medication were looked at and menu plans were discussed. The recruitment procedures and staffing rotas were looked at as well as the training provided to the staff. This included inspection of 3 staff files. A tour of the home was undertaken. What the service does well: People receive an assessment of their needs before they are offered a place in the home. The care plans of residents are reviewed every month to see if any changes to their care are required. Residents’ health care needs are well met. Staff respond promptly if people feel unwell or require the input of the GP or District Nurse. People said that their needs are well met by the home and that there is a caring staff team. ‘They are a grand lot of girls. They attend to my needs very well.’ There is a relaxed atmosphere in the home and visitors are made welcome. Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 6 There are safe practices in the administration of medication. Only senior staff administers medication and they are well trained. Meals are plentiful and nutritious with plenty of fresh food. The majority of the residents said that the food was good. There is a homely environment that is well maintained. Everywhere was very clean. What has improved since the last inspection? What they could do better: 6 requirements have been made that the home must address: They have been asked to provide better information to prospective and current residents about the home in the Service User Guide, to include information about the change of ownership, about fee levels and about how to make a complaint. At least 2 satisfactory references must be obtained for all staff working within the home. This was not always the case. They must ensure that staff are properly vetted before they commence working in the home. They need to check the Protection of Vulnerable Adults (POVA) register while waiting for a full CRB (Criminal Records Bureau) check if anyone is allowed to start before the full CRB has been received. This was an immediate requirement. Staffs training records need to be audited and any outstanding mandatory training must be provided to relevant staff. The manager must ensure that any staff that deal with residents’ finances are fully aware of the procedures that must be followed to ensure proper records are kept. All records about residents must be kept in a secure place so that their confidentiality is maintained. Recommendations about good practice were also made: Residents should be involved in the review of their care plans and make their own choices about such things as when to have a bath and what activities they Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 7 would like to join in, and have it made clear to them about alternative choices at meal times. The manager needs to get the most up to date information about what to do and who to contact should any issues about safeguarding adults (dealing with abuse) ever arise. Formal training of staff about safeguarding would also be good practice. Pictorial signs on such as bathroom and toilet doors could help people with dementia to identify where these facilities are, to aid their independence. A review of the staffing levels linked to the needs of the residents will help the manager decide if more staff are needed at particular times of the day. Better records about staff training need to be kept to evidence all of the training that takes place. Residents’ money would be kept more securely if kept in a locked safe or box. It may currently be kept in an unlocked filing cabinet in the office, which may on occasion be left open. Staff records would be better kept in a locked filing cabinet than on a shelf, to ensure the information is kept confidential. There is a fire risk assessment for the building but an individual fire risk assessment for each resident would better inform staff about the support each person would need to help them to a place of safety should a fire break out in the home. 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. Nethermoor House DS0000069415.V358900.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 Nethermoor House DS0000069415.V358900.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): Standards 1 and 3. Standard 6 does not apply to this home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who may use the service and their representatives need better information about the home to enable them to assess if the service will meet their needs. Prospective residents are however appropriately assessed to see if their needs can be met by the home. EVIDENCE: The Statement of Purpose was not seen at the visit but had been amended satisfactorily at the point of registration of the service following requirements made then by the Commission. The home was classed as a new registration because of change of ownership. There was a Service User Guide available that is provided to prospective and new residents. However, the Guide did not contain any information about fees, Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 10 about how any special needs such as for those people with dementia are catered for or any reference to residents’ views about the service, and much of the information was out of date, such as still referring to the previous owners. A requirement is made that the Service User Guide is amended to ensure that it is up to date. There was a copy of the local authority needs assessment and care plan available in each resident’s file and a needs assessment had been undertaken by the manager. The needs assessment used a ‘scoring system’ to determine the level of support required in all aspects of care. From this a long-term assessment and care plan was drawn up, with the residents’ needs reviewed on a monthly basis. There was sufficient information in the needs assessment for the home to determine if the individual’s needs could be met by the home. A relative of a resident who was a recent admission to the home confirmed that her mother had been visited whilst in hospital by the manager who undertook a full assessment of her mother’s needs. The daughter’s input had also been sought. Nethermoor House DS0000069415.V358900.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): Standards 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are well met but better care plan information would evidence this more readily. Residents would benefit from a greater involvement in the planning of their care to give them more control over the service that they receive. EVIDENCE: There was a plan of care in each of the files. The plan uses a scoring system to assess the level of support required. This is reviewed monthly and combined with other information about any changes to the person’s needs to provide an overall care plan. The plan is then supported by daily contact information. There was no evidence that individual residents are involved in the review of their care plan, although a senior carer said that this sometimes happened. It is recommended that residents wherever possible are involved in the review of Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 12 their care plan to give them more control over the service that they receive. This should be documented. The plans overall contained satisfactory information to enable staff to support the residents, but there was at times conflicting information in the various parts of the records, and also the complete information about each person had to be searched for throughout the documents. The plans could include more information about who and what is important to the person, their goals and aspirations, their skills and abilities, and how they make choices in their life. There were some risk assessments in place but these again could be better documented. The care plan overall did not address outcomes for residents. There was, however, reference to a key worker who also provides an occasional brief report on discussions held with the resident. The addition of the above information, coupled with the pulling together of the support needs required by residents into a summarised form would give a more ready picture of each person’s needs to assist staff to deliver a personalised and consistent person centred service. The manager is asked to consider this. Staff spoken with, however, could give good information about the needs of each resident that they were asked about. The majority of the residents were spoken with, some in greater detail, and they all said that the staff understand their needs and meet them very well. ‘They are a grand lot of girls. They attend to my needs very well.’ 2 relatives also endorsed that care needs are well met. There was very good evidence to show that the health care needs of residents is fully met. There was good recording of all contacts with health professionals. 2 people had bed sores and there was evidence of prompt contact with the District Nurse and of follow up action, and of equipment in place to promote tissue viability. There was evidence of nutritional screening of residents on admission and follow up where required, and appropriate actions taken where there were issues of any concern. There was evidence of continence advice being sought for individuals. On the day of the visit a GP came to see 4 people who had raised concerns on that morning with staff about their health. All of the residents who were asked said that the staff always responded promptly to any health needs identified. The procedure for ordering, receipt and return of medication was discussed with the senior carer and considered satisfactory. There are no residents that administer their own medication. The medication round was observed and good practice was followed. There was only 1 resident who had controlled drugs and these were appropriately stored and recorded. Individual prescriptions for creams were appropriately stored. There was information in place from the GP for PRN ‘ as and when needed’ medication. Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 13 The senior carer confirmed that only senior staff administers medication. There was evidence that all of these staff had received external training. Residents were treated with respect and their dignity and privacy was respected throughout the visit. Staff were seen to respond to requests to use the toilet promptly and people’s privacy was upheld when doing so. Staff always knocked on bedroom doors. A resident with short-term memory loss who kept repeating the same comments about not being in the home for very long (although she was a long term resident) was responded to in an appropriate manner and with patience. Staff spoken with and asked about residents’ needs and how to approach individuals had a good understanding of the principle of respect. A GP visited and it was seen that the individual residents were attended to in private. The home is reminded that screening curtains to respect the privacy of residents in double bedrooms should be in place at all times. Nethermoor House DS0000069415.V358900.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): Standards 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents make some choices about their lifestyle. While there are some social and recreational activities provided these could be improved to meet individual’s expectations. EVIDENCE: Residents said that they were able to get up and go to bed as they pleased. Their preferred times were recorded in their individual plans. Discussions with staff evidenced that there are set times for people to have a bath. This timing is to meet the needs of the service for when staff are more readily available, and not always in line with the personal choice of residents. A recommendation is made for closer involvement in their care planning for residents. Each care plan had a record of the activities that residents had taken part in recorded in their individual file. This included such as occasional reminiscence, Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 15 bingo, art, and armchair aerobics, sing a longs. There was a schedule of activities, one for each day displayed on the notice board. However the large majority of the residents said that there were not many such activities taking place of late. This was also stated by a visiting relative who said that she visits at different times and days of the week but never finds much going on. She had read the programme of activities on the notice board and rarely saw any signs of such activities happening. People said that there is occasional outside entertainment. A resident who stays in her room said that this is because there is nothing going on in the lounges and people just sleep. The activities when provided seemed to be a ‘one size fits all’ approach with little focus on gender, needs of people with dementia, getting residents to choose what they would like to do. There were no clear activity plans centred on the needs of the people with dementia. The home is recommended to discuss with the residents about the activities that they would wish to see provided, and to develop activities that are appropriate to the different needs of each resident. There was a very relaxed atmosphere in the home and relatives were coming and going throughout the day. Those spoken with said that they are always made very welcome in the home and their relative always choose where they want to see their visitors. There was evidence that the majority of residents handle their own financial affairs, some with the support of their family. Rooms were well personalised and residents confirmed that there had been no issue about them bringing their chosen personal belongings into the home. Some residents were aware of their right to access their personal records. There is a 4 week rolling menu plan that gave evidence of a varied balanced diet. There was a good breakfast choice, sandwiches or snack meal in the evening and a cooked meal at lunchtime. Residents and staff confirmed that they were given supper. There were plentiful drinks on offer throughout the day. The majority of residents said that the food was good. In discussion with the residents they all seemed to be unaware that they could have an alternative to the main meal should they not wish what was on offer, although staff were clear that this is so. It is recommended that an alternative choice is displayed on the menu board each day and that resident’s attention is brought to it. The cook confirmed that special diets are catered for. There were good nutritional screening records with information about individual needs. 1 resident required help with eating and she was seen to be assisted sensitively and discreetly by a member of staff. Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 16 Nethermoor House DS0000069415.V358900.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): Standards 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns. They are protected from abuse, although the training of staff and up to date information being kept in the home could further strengthen this. EVIDENCE: There is a Complaints Procedure available for residents and displayed in the entrance hall. The Complaints Procedure provides sufficient detail for residents to understand how to make a complaint. The procedure is also available in the Service User Guide. However the information is out of date in that it makes reference to the previous owners and an out of date address for the commission. Residents however, confirmed that they knew about their right to complain and that they would speak to staff and the manager. A requirement about updating the Service User Guide is contained in an earlier section of this report. There have been no concerns or complaints received by the commission about this service. Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 18 There had been no complaints recorded in the home since the last inspection. However there was a current issue about the laundry of a resident’s clothing that cam to light during the inspection. Whilst the home was responding appropriately to this, it was not recorded in the complaints log, and there was no evidence of a separate ‘grumbles book’ used in the home where issues such as this could be recorded. This would enable a record to be kept of details about more minor informal expressions of concerns to assist in evidencing quality assurance by providing evidence that such concerns are listened to and acted upon. A recommendation is made that all issues and their outcome are recorded. This could be in a ‘grumbles book’. The home has an abuse policy that satisfactorily refers to all areas to be considered when ensuring the safeguarding of adults. The staff had difficulty in locating the policy and seemed unsure of what was being referred to. The document was an old one and the copy of the local multi-disciplinary procedures held in the home was also a much out of date copy. The manager is referred to the relevant current document: ‘Safeguarding Vulnerable Adults in Staffordshire and Stoke-on-Trent – Policies and Procedures – May 2007. This is needed in the home to enable the manager to demonstrate she has up to date knowledge of referral processes so that any issues would be dealt with appropriately. Staff training records inspected did not evidence that these staff had received training in safeguarding adults from abusive practice. A long standing senior member of staff confirmed that she had received this training some time ago, but was unaware of any training being provided to more recent staff. A staff member who had worked in the home for some 12 months confirmed that she had not received this training. When questioned however she had a very clear understanding of what constitutes abusive practice and her reporting responsibilities over various scenarios that were set. A recommendation is made that all staff are provided with formal safeguarding adults training. There was evidence of good staff induction procedures. A member of staff confirmed that she had worked in the home for a month before she provided any personal care alone. Both she and the manager also said that staff were not allowed to bathe residents until they have undertaken their NVQ2 (National Vocational Qualification) in care. Training records evidenced that some staff had received training in understanding the needs of people with dementia, and staff confirmed that there was another course planned for more recent staff. This is needed to ensure that all staff are aware of how to deal with verbal or any physical aggression. Issues relating to policies and procedures and the safe storage of residents’ monies are addressed in a later section of the report under ‘management and administration’. Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment. Additional measures to support the needs of people with dementia to recognise areas of the home would further promote their independence. EVIDENCE: Nethermoor House is set in its own grounds and is reached by a long drive. There is ample parking at the front of the property and the rear garden and side access is enclosed by high fencing to ensure safety. Over the years the home has been extended to provide more bedrooms. The original part of the home maintains a number of original features. Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 20 The communal space used by the service users is on the ground floor. There are 2 lounges; a large lounge situated next to the dining room, and a smaller quiet lounge. The communal areas are attractive and provide a homely feel. There are single bedrooms on the ground floor and both single and double bedrooms on the first floor. The first floor is accessed via the shaft lift or stairs. There are 2 single rooms that the commission considers unfit for purpose as they are too small, and a condition or registration was made at change of ownership that these be used only as long as the current residents remain there. The senior carer on duty said that the same residents remained in these rooms. 2 people who share a room said that they are happy to do so. There was evidence of some double rooms now only accommodating a single resident to comply better with privacy for residents. People said that there was no problem about personalising their rooms. All of the rooms seen were comfortable, safe and homely. There are plentiful bathing and toilet facilities located throughout the home. Nethermoor does not provide en-suite facilities. The home was very warm at the time of the visit. This was appreciated by many of the residents who said that they felt the cold. However one lady who remains in her room was very uncomfortable with the heat. The provider needs to consider the individual needs of the residents. The home currently has 4 residents with dementia needs. There was no evidence of any additional consideration to enable these residents to become more independent in their surroundings, such as signage for bathrooms and toilets. It is recommended that this be considered. The environment was well maintained and in good order and very clean throughout. The laundry is well sited and although small provides appropriate equipment to meet the needs of the home. Policies and procedures for the control of infection were discussed with the senior carer and were considered satisfactory. Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a caring staff team who support the residents and ensure the smooth running of the home. Staff recruitment procedures and staff training need to be strengthened to further develop the quality of the service being delivered to residents. EVIDENCE: The staffing rota showed that there are 3 staff available in the morning, 2 in the afternoon and 2 waking night staff. These numbers were evidenced at the inspection. These staff support 19 residents, including currently 4 people with dementia. Care staff also undertake cleaning duties. There is always a senior carer available on each shift. The home does not use agency staff and any shortfalls in staffing are covered by the staff team undertaking additional shifts. There was mixed information about the adequacy of the staffing levels. Residents said that care staff responded to their needs speedily when they called for them via the staff call system. They made no adverse comments about staffing levels. They were full of praise for the staff and said that their Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 22 needs were met very well. The call alarm was heard throughout the visit and staff responded in a satisfactory timescale. Discussions with all staff evidenced however that they were rushed at times, particularly in a morning. There was evidence to support this, as residents are not able to have a bath until a set time. A relative also said that activities seem to have reduced somewhat of late, and they thought this may be linked to staffing levels. The relative was also clear however that her mother’s needs are well met and that she has never had any concerns about the care that is delivered. She said that she also heard this said by other relatives. A relative whose mother had only been in the home for 3 weeks said that staff responded well to her mother’s needs. A recommendation is made that the manager undertakes a review of the staffing levels linked to the needs of current residents, and takes any necessary action, that is identified from this review. A discussion with a staff member evidenced that she had submitted an application form, had undergone an interview and that references were sought before she commenced working in the home. She confirmed that a CRB (Criminal Records Bureau) check had been received about her. The staff files inspected evidenced various missing recruitment information. 1 had no application form, for another there were no references. Staff had received a statement of terms and conditions. A requirement is made that full information and documents are available in the home relating to all staff. In particular this relates to the missing references. Each staff file seen showed receipt of a CRB but it was found that these staff had all commenced working before it was received. There was no evidence of a POVA First (Protection of Vulnerable Adults) check being made, which must be in place if staff commences working in the home prior to their full CRB being received. An immediate requirement was made about this. Staff said that they had a good induction and shadowed a senior member of staff for a month before providing any personal care. They are not allowed to bathe residents alone until they have their NVQ2. In each of the staff files there was an induction booklet that meets requirements but large sections had not been completed making it impossible to verify the full induction training received. The manager is recommended to complete the induction record in full whenever staff receives the appropriate training, to provide evidence. There were shortfalls in areas of mandatory training. Evidence in records and discussions with staff showed that this relates to all staff (except the cook) for food hygiene training and there were no records or evidence from staff of health and safety training. There was evidence of training in infection control, moving and handling, first aid and fire training. A course about the needs of Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 23 people with dementia was planned for those staff not in receipt of this. Senior staff also had external medication training. A requirement is made that the manager undertakes an audit of staff training and that training in all mandatory areas is provided to all staff where there are deficiencies. A senior member of staff provides moving and handling training to new staff in between an external training provider giving this training. Whilst the staff member said that she had received training in order to do this the manager is recommended to satisfy herself that this training was sufficient to enable the senior to provide moving and handling training competently and safely. This is usually evidenced by a ‘train the trainer’ certificated course. Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 24 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): Standards 31, 33, 35, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is satisfactorily managed, but more attention to some areas of management responsibility is needed to develop the service further for the benefit of residents. EVIDENCE: The current manager was the previous owner/manager of Nethermoor House before it changed ownership to a national provider last year. The manager was not on duty at the time of the inspection but staff reported that they had not Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 25 noticed any changes in the operation of the home. Residents, relatives and staff alike spoke well of the manager. There were some issues at change of ownership. The commission had to alert the provider that the home was operating illegally initially as no application was received by the organisation to register a responsible person for the home. This has since been addressed. The Statement of Purpose for the home was not seen at the visit but has been previously considered appropriate by the commission. The Statement of Purpose sets out the aims and objectives of the service but staff on duty were unaware of the document. It would be expected that its content be discussed with the staff to ensure that the staff team are working together with the manager to fulfil its aims. There was evidence that residents are consulted by questionnaire about their satisfaction with the service. There was no evidence to show that relatives are formally surveyed separately but many contributed to the process by supporting their relative to complete the forms. It would be a further demonstration of quality assurance if relatives were consulted about their views of the service and how it could be improved. The home keeps some money for currently 4 residents. There appears to be a lack of clarity about which staff are able to deal with residents’ monies and consequently the procedures to be followed for recording transactions and issuing receipts. The manager is required to ensure that the policy and procedure for dealing with residents’ finances is appropriately understood by the relevant staff so that a complete record of all money or other valuables deposited for a resident for safekeeping is appropriately maintained. There was some money belonging to a resident kept insecurely in an unlocked filing cabinet. Staff reported that the office is itself locked whenever the manager or senior staff vacates the room. Whilst this is understood the nature of care means that there could be occasions when the office is left unlocked and unattended. The manager is recommended to keep all residents’ money in a secure place such as a locked safe, drawer or box. Residents’ records are kept on open shelving in an open part of the home leaving each record accessible to other people other than care staff and the individual resident. Staff records were stored on an open shelf in the office. A requirement is made that all of the records relating to residents and staff are kept securely in the home. Safe working practices were evidenced throughout the inspection. There was good accident recording that linked well to daily contact sheets and with an analysis of the incident and with new action points noted. All relevant records Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 26 relating to health and safety in the home were maintained. There was regular maintenance of equipment such as bath hoists. An earlier part of the report refers to the absence of health and safety training for all staff. Fire records were maintained appropriately. The staff said that they had an annual fire safety training session with one planned for the next few weeks. Periodic fire drills were reported and evidenced. The manager is reminded that night staff may require more regular drills. There were individual risk assessments for fire for bedrooms but there was no evidence of any individual risk assessments in the event of a fire for residents, explaining to staff what support they would need to give each individual to assist them to a safer area in the home should a fire break out in a fire compartment where they were situated. A recommendation is made that an individual fire risk assessment is undertaken for each resident. This is needed to comply with up to date fire legislation. Residents are comfortable within the home, their essential care needs are met and there is a good focus on ensuring that their health needs are met. They are supported by a caring staff team. However, this report raises some issues that the provider and manager need to address to achieve positive development of the service to raise the quality of the service further. Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 27 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 2 X 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 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X 2 2 Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 5 Requirement Timescale for action 07/04/08 2 OP29 19 and Schedule 2 19 and Schedule 2 OP29 3 Revise the Service User Guide to include information, for example, about the change of ownership, information about fees and about how to make a complaint. This will ensure that people have up to date information about the service that they can expect. Ensure that at least 2 07/04/08 satisfactory references are obtained for all staff working within the home. This will help ensure the safety of residents. Ensure that a clear POVA 07/02/08 (Protection of Vulnerable Adults) check is received for any staff that commences working in the home before a full CRB (Criminal Records Bureau) check is received. This will help ensure the safety of residents. This was an immediate requirement Undertake an audit of the training received by staff, and provide mandatory training to individual staff in all of the areas in which they are deficient. A DS0000069415.V358900.R01.S.doc OP30 4 18(1) c 07/04/08 Nethermoor House Version 5.2 Page 29 fully trained staff team will help ensure the health, safety and welfare of residents. (The date shown is the date by which outstanding courses should be planned by. It is recognised that dates for delivery of the actual training may be later than this). Ensure that the relevant staff appropriately understands the policy and procedure for dealing with residents’ finances, so that a complete record of all money or other valuables deposited for a resident for safekeeping is appropriately maintained. Keep the care plan and other information relating to each resident securely in the care home so that their confidentiality is maintained. OP35 5 17(2) and Schedule 4 07/04/08 OP7 6 17 and Schedule 3 07/04/08 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 OP7 Good Practice Recommendations Involve residents, where appropriate, in the review of their care plans. This will enable them to exercise choice about the service they receive and to retain control over their lives. Enable residents to exercise choice over the pattern of their day. This in particular relates to residents’ choice being facilitated about the time that they have a bath. Give consideration to the activities that are provided to ensure that they meet the different needs of the residents and involve residents, where appropriate, in developing the plan of activities. This will help to ensure that the DS0000069415.V358900.R01.S.doc Version 5.2 Page 30 OP12 2 3 OP12 Nethermoor House OP15 4 OP18 5 OP18 6 OP19 7 OP27 8. OP30 9 OP30 10 OP35 11 OP29 12 OP38 13 activities meet residents’ needs and wishes. Show alternative meal choices on the menu board and bring residents’ attention to it so that they are encouraged to make their own choices. Obtain the current copy of multi-agency procedures relating to safeguarding adults, namely ‘Safeguarding Vulnerable Adults in Staffordshire and Stoke-on-Trent – Policies and Procedures- May 2007. This will help ensure that appropriate procedures are followed in the home should any alleged incident arise. Provide formal safeguarding adults training to staff to help ensure their knowledge about safeguarding residents. Provide pictorial signs on e.g. bathroom and toilet doors. This will help residents with dementia needs to retain independence. Undertake a review of the staffing levels linked to the needs of the residents, and take any action identified from the outcome of the review. Such a review will help to evidence the staffing levels needed to support the residents throughout the day. Maintain up to date records for all induction training, to ensure an audit trail. The manager should satisfy herself that the member of staff who provides moving and handling training to other members of the staff team has been appropriately trained, to ensure the health and safety of residents and staff. Keep all money belonging to residents in a secure place to ensure its safekeeping at all times. If the office is left unlocked for any reason this will give added security for any money or valuables kept in the office. Keep staff records in a secure place to ensure the confidentiality of the information. Undertake an individual fire risk assessment for each resident to inform staff about the support each person would need to help them to a place of safety should a fire break out in the area where they were situated within the home. This will help ensure the safety of residents and is needed to comply with current fire regulations that are overseen by the fire authority. Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Nethermoor House DS0000069415.V358900.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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