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Inspection on 04/06/07 for Netherton Green Nursing Home

Also see our care home review for Netherton Green Nursing Home for more information

This inspection was carried out on 4th June 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is pleasantly decorated and furnished with an ongoing refurbishment programme. There is good access throughout the building where residents are accommodated and a range of aids and adaptations available for dependent people. All residents have an assessment of their needs before agreement is made for them to come and live at the home. Care planning is good with a new care plan programme recently implemented, which has been positively received. Service users are treated with respect and are able to retain control over their lives within the home. The home has sufficient staff that receive regular and required training and has 45% of its care staff qualified to at least National Vocational Qualification level two. Residents and visitors consistency said that staff are: " Very good, very, very caring and very helpful". The home has an experienced manager who provides strong and effective leadership. She has inspired her staff to develop and enhance the care that is given. Excellent developments were noted to have been undertaken on Primrose with the new Unit Manager. There are appropriate procedures in place for the safe recruitment of staff, to highlight concerns and to protect the vulnerable people who live at Netherton Green.

What has improved since the last inspection?

The new care planning programme has proved to be an excellent development. It provides staff with signposting to ensure that all care instructions are in place to meet residents needs. It was also very positive that all trained staff received training in the care planning programme immediately before its implementation and have received ongoing support in any areas that they were unsure. The refurbishment programme has also been ongoing with additional refurbishment of Primrose. The completion of the "pub" on this unit is eagerly awaited by residents, visitors and staff and will be an excellent development for residents. The home has a new manager who is inspiring the staff to generate ideas to develop practice and improve the care that people who live in the home receive.

What the care home could do better:

There have been improvements in the storage and administration of medicines but more are required. The rooms where medicines are stored need to be cooler than present, as current temperatures mean that medicines may not be either be safe or effective. Staff need to ensure that residents this is recorded. Activities do take place with activity coordinators for the three units that have permanent residents. Activities though must reflect residents` needs as identified by their social plans of care. A choice of meal is always provided but further exploration of what meals residents like and this should be reflected in the homes menu. The home has an invaluable intermediate care unit for people who have been in hospital but are not yet ready for discharge. Care plans and the care that staff give must reflect the reasons why people are transferred to Saltwells, which is not currently the situation

CARE HOMES FOR OLDER PEOPLE Netherton Green Nursing Home Bowling Green Road Netherton West Midlands DY2 9LY Lead Inspector Mrs Amanda Hennessy Unannounced Inspection 4th June 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Netherton Green Nursing Home DS0000004886.V335218.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. Netherton Green Nursing Home DS0000004886.V335218.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Netherton Green Nursing Home Address Bowling Green Road Netherton West Midlands DY2 9LY 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) 01384 410120 01384 413460 taylorgr@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Limited vacant post Care Home 120 Category(ies) of Dementia - over 65 years of age (60), Old age, registration, with number not falling within any other category (60), of places Physical disability (30), Terminally ill over 65 years of age (30) Netherton Green Nursing Home DS0000004886.V335218.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Service users to include up to 60 DE(E), 30 PD, 30 TI(E) and up to 60 OP One service user accommodated on Darby House in the category of OP may also be SI(E) and will remain until such time that the current service users placement is terminated. Two service users accommodated on Darby House in the category of OP may also be DE(E) and will remain until such time that the current service users placements are terminated. One service user accommodated on Darby House in the category of OP may also be LD and will remain until such time that the current service users placement is terminated. One service accommodated at the home may be LD(E). This will remain until such time that the current service users placement is terminated. One service user, named in the variation application dated 13 May 2004, accommodated on Windmill House in the category DE(E) may also be MD(E) and will remain until such time that the current service users placement is terminated. Windmill House to accommodate 30 service users in the category DE(E) who are 60 years and over. 9th March 2007 7. Date of last inspection Brief Description of the Service: Netherton Green Nursing Home is a purpose built home consisting of four separate and spacious bungalows set in attractive landscaped grounds. Windmill and primrose accommodate up to thirty people with dementia, Darby up to thirty frail elderly and Saltwells is the intermediate care unit for Dudley Group of Hospitals. Netherton Green Nursing Home is a private home owned by BUPA. All bedrooms are single with toilet and bathroom facilities close by and each unit has a large communal lounge/ dining room, which has smaller partitioned off areas. A kitchenette is situated off the main lounge/dining area, where drinks are prepared, a fridge and microwave are also available. Administration services are situated in a separate administration block where the Manager who has a responsibility for the complex has her office. A central laundry and kitchen are also situated in this block. The home is situated off Bowling Green Road, Netherton. The home has ample car parking and is accessible by public transport. Fees range between £343 to £662.50 and are dependent on peoples needs and the room that they occupy/. Toiletries, hairdressing, newspapers and non NHS Netherton Green Nursing Home DS0000004886.V335218.R01.S.doc Version 5.2 Page 5 Chiropody are not included in the fee and must be provided at residents’ own expense. Netherton Green Nursing Home DS0000004886.V335218.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by two Inspectors, Mrs Amanda Hennessy and Mrs Mandy Beck. The inspection was carried out over two days. The inspection included a tour of each of the units, talking to service users, staff and visitors and a review of records. Twenty-three service users completed questionnaires that asked their views on the home, which positively identified their life at the home. Care records were reviewed as part of the “case tracking” of nine people who live throughout the home. The home is manager is Sheila O’Connor. The registered proprietor is BUPA Care Homes. Nineteen of the previous twenty requirements have been met, three new requirements were made as a result of this inspection. What the service does well: The home is pleasantly decorated and furnished with an ongoing refurbishment programme. There is good access throughout the building where residents are accommodated and a range of aids and adaptations available for dependent people. All residents have an assessment of their needs before agreement is made for them to come and live at the home. Care planning is good with a new care plan programme recently implemented, which has been positively received. Service users are treated with respect and are able to retain control over their lives within the home. The home has sufficient staff that receive regular and required training and has 45 of its care staff qualified to at least National Vocational Qualification level two. Residents and visitors consistency said that staff are: “ Very good, very, very caring and very helpful”. The home has an experienced manager who provides strong and effective leadership. She has inspired her staff to develop and enhance the care that is given. Excellent developments were noted to have been undertaken on Primrose with the new Unit Manager. There are appropriate procedures in place for the safe recruitment of staff, to highlight concerns and to protect the vulnerable people who live at Netherton Green. Netherton Green Nursing Home DS0000004886.V335218.R01.S.doc Version 5.2 Page 7 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. Netherton Green Nursing Home DS0000004886.V335218.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 Netherton Green Nursing Home DS0000004886.V335218.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): 2,3,4,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People wishing to live at the home have their needs met, although this is not always assured for people who come to the home from hospital requiring intermediate care. The availability of terms and conditions of residency would provide people with essential information about the home. EVIDENCE: Contracts for residency at the home are available for residents who are privately funded with placing contracts available for Social Services funded residents. Feedback form residents was that they didn’t feel that they had sufficient information before they came to live at the home and this was particularly the position for people who came to the home from Dudley Group of Hospitals for intermediate care. Terms and conditions of residency are not available and if available would provide residents with the majority of information they were uncertain about. Netherton Green Nursing Home DS0000004886.V335218.R01.S.doc Version 5.2 Page 10 All Windmill, Primrose and Darby residents have a comprehensive assessment of needs. The unit managers on these units go out to assess people in their own homes or in hospital prior to their admission to the home. The new QUEST care documentation that the company has introduced provides service users with a comprehensive assessment that readily identifies their needs and any associated risks to service user and is an excellent development for care planning. Saltwells provides intermediate care for Dudley Group of Hospitals. People are transferred to Saltwells when their acute care in hospital has been completed but they need more support before they go home or are unable to go home and need further residential care. People are assessed for their suitability for intermediate care by hospital staff. It was evident that this has been problematic and not all people have been suitable for Saltwells due to their medical conditions. Saltwells has physiotherapists and Occupational Therapists who are also able to assist residents Monday to Friday; a Doctor from the hospital also visits Saltwells most days. Discussions with staff highlighted that they had had no training in “intermediate care and what it is” and when asked, were not aware of the aims of intermediate care. The lack of staff understanding of their role was also reflected by care instructions within people’s plans of care. Care records had no inclusion on what residents could do and their needs when they went home such as giving their own medicines. Staff agreed that Occupational Therapists and Physiotherapists visit residents daily but care records seen also did record this. Staff were also unaware what the Occupational Therapists and Physiotherapists had been doing with residents and what they should be doing to continue supporting their work when they were not available for example frequency and distance that they should be walking. It is disappointing that this valuable facility is not fully being effectively utilised to the benefit of residents and the use of valuable NHS funds. Windmill and Primrose provide care to people with dementia. It is positive that staff on these units have had some dementia care training. Staff said the training that they had had, had been invaluable but they would like more practical advice on how to deal with people with dementia on a day to day basis. Windmill staff also said that they would like some training sessions on other mental health issues as they have service users with schizophrenia and depression and did not really understand their needs. Netherton Green Nursing Home DS0000004886.V335218.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users care is planned with good instructions available to staff to tell them what they need to do to meet people’s needs. Medicine policies and procedures are generally satisfactory and safeguard service users although further improvements are necessary. Service users are treated with respect and their right to privacy is upheld. EVIDENCE: All residents on all units had a plan of care and risk assessments that addressed their needs. It was pleasing to see that there was a care plan for a Primrose resident that gave instructions to staff how this persons challenging behaviour should be managed whilst continuing to meet this persons needs. Another care plan on Windmill house had a detailed description of how the resident wanted assistance to get ready for bed at night and another gave staff information about how that resident preferred to sleep. There is still some work to do before all of the plans are truly person centred but they are Netherton Green Nursing Home DS0000004886.V335218.R01.S.doc Version 5.2 Page 12 making good progress with it. The new Quest care documentation has had a positive impact on care planning and has helped to plan and prioritise care needs for people who live at the home. Care records had not been reviewed for May, but staff were aware of this and said that they had taken so long to implement the new care records some of the evaluations had fallen by the wayside. Other shortfalls noted that when a risk was identified with nutrition the care plan stated that the service user should be weighed on a weekly basis but this had not happened. The care plan was implemented on the 20/05/07 only one weight was recorded. Other people who should have been weighed monthly were not. Staff said that this is sometimes due to the fact that they have to share weighing scales with other units. This was discussed with the manager who confirmed that she has already ordered another set of weighing scales for the unit. There were also concerns about the lack of appropriate slings for the hoist, on Windmill they only have a medium sized hoist sling, again this was discussed with the manager who said that new slings were on order including a specialist sling for one service user. All service users have access to community services such as chiropody, dentistry and the optician. There were risk assessments in place that looked at the reduction of pressure sore development, falls, nutrition and moving and handling and are reviewed monthly. Qualified nurses administer medication on all units. The administration of medicines is generally satisfactory although further improvement is required to give greater assurance that residents receive the correct medicine at the required dose, which has been stored safely at required temperatures. There were a number of medicines on medication charts that did not have clear instructions when this medicine should be given. One entry on the medication record stated Oramorph 10mg/5ml “take one or two spoonfuls every 4 to 6 hours when required”. This is a greater concern as there are no care plans for “as required” medicines. Staff do record the temperature of the rooms where medicines are stored and the drugs fridge. Records seen show that frequently the room where medicines were stored on Darby was above the “ safe” temperature (26oC) that the majority of medicines should be stored at to give assurance of both the safety and effectiveness of the medicine for the residents. Staff were frequently do not sign for the administration of creams and lotions and in some cases where an entry on to the Mar had been made the staff have entered a tick. The home has also identified a number of concerns in relation to its supplying chemist and currently in the process of changing its chemist. The new chemist will provide greater support to staff and will undertake regular audits with advice for the safe storage and administration of medicines, providing greater assurances and services to residents. Staff were sent to treat service users with respect and protecting their privacy throughout the inspection. When staff were spoken to they also demonstrated Netherton Green Nursing Home DS0000004886.V335218.R01.S.doc Version 5.2 Page 13 a good understanding of how to protect residents privacy and dignity. Residents spoken to also confirmed and consistency said: “ They are very good, they are very, very caring and very helpful”. Netherton Green Nursing Home DS0000004886.V335218.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): 12,13,14,15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has social opportunities for residents although more are required to meets people’s expectations and preferences. There is always a choice of meal although residents do not always like the choices available. EVIDENCE: Each unit with the exception of Saltwells the Intermediate Care Unit, has its own activity worker who is employed 30hours a week. The role of the activity workers is to identify residents’ interests and plan activities around their interests, capabilities and choices. Staff are currently planning a trip out to the botanical gardens with residents. Recent activities have been gardening, bulb planting, painting, quizzes and sing-alongs, although it did appear that it was staff that choose these activities. Saltwells have no planned activities, as this is not part of the contract with the Primary Care Trust, although the Manager said that they are welcome to attend entertainment on the other houses. Residents said that they were bored and had nothing to do: “There is nothing to do we just sit, its because we are NHS patients. One of the care staff started a sing-along the other day of all the old songs which was great but I haven’t seen her since”. Netherton Green Nursing Home DS0000004886.V335218.R01.S.doc Version 5.2 Page 15 Primrose is currently undergoing refurbishment to make it a more stimulating environment for people with dementia. There is now a “ pub” in the unit that is complete with bar and piano, that residents can visit with their friends and families for a drink. The home has a four weekly menu that is regularly updated and offers a choice at each meal. Mealtimes have been adjusted so that all service users have their breakfast before 09.30, but they are able to lie in if they wish to do so or even have their breakfast in bed. Comments about the meals were variable and although some people did say they enjoyed the meals many felt there could be improvement in the choice available. Residents said: “ I think there could be more choice” and “I think we should have more choice at lunchtime, there is a full choice at breakfast, you can have anything even a full English if you want”. Another comment received before the inspection was: “They do not seem to cater for old people they seem to have special dishes which old people do not like. Old people like basic plain food not all these fancy dishes most of his food is thrown away in a bucket which is a waste of food”. One lady was given her dinner and when she was told it was chicken said that she didn’t like chicken. Staff did then offer her the alternative- salmon and broccoli quiche but she said of the two she would try the chicken, no other options were given to her. Inspectors observed meal times on Primrose, Windmill and Darby and sampled the food when all residents had been served. Portion sizes of main meals were found to be generous although puddings were small. One relative said; “ The puddings have changed to small little dishes. Mom used to have more than this very small portion”. Inspectors finding confirmed residents’ views that improvement could be made. Few of the residents eat their meals saying that they didn’t like it, the carrots and cabbage were soggy from being kept warm in the serving trolley, the food on Windmill was also found to be luke warm and generally was found to be tasteless. Mealtimes on Windmill were disorganised. Windmill have thirteen people who need assistance with eating and drinking, one care staff serves the food, another gives it out to the service users, the remaining three care staff disperse to feed service users, the trained nurse does help. Dining tables are laid and some units also had table clothes but generally the dining area is unattractive and mealtimes are not made “special”. Staff said “we need more chair tables so we can feed the service users, the ones we have are getting dirty and difficult to clean.” Netherton Green Nursing Home DS0000004886.V335218.R01.S.doc Version 5.2 Page 16 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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has appropriate policies and procedures to highlight concerns and complaints to safeguard service users. EVIDENCE: The home has a detailed complaints procedure that is prominently displayed on each unit and in the administration block. The home have received five complaints, and of which three were also sent to the Commission for Social Care and Inspection. The complaints log identified that all complaints since the current manager has been in post have been timely and comprehensively investigated but records of previous complaints were not complete. Service users and their families spoken to said if they had any concerns they would discuss them with the Unit Manager or the Home Manager. The home have appropriately made three Adult Protection referrals with required actions undertaken to safeguard its service users. Confirmation from the Manager that beds have appropriate mattresses, as a resident had slid off their bed on their mattress as no footboard was in place has not been received. The home has appropriate policies to ensure that staff who are not suitable to work with vulnerable people do not do so by robust recruitment and selection Netherton Green Nursing Home DS0000004886.V335218.R01.S.doc Version 5.2 Page 17 procedures. Staff have received training in the Protection of Vulnerable Adults. Staff spoken had appropriate knowledge of what is abuse and what actions they must take if any allegation of abuse is made to them. Netherton Green Nursing Home DS0000004886.V335218.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. The home is pleasant, homely and generally well maintained although there are insufficient assisted bathing facilities available. Infection control within the home is safeguards its service users. EVIDENCE: The units are generally pleasantly decorated, clean and kept tidy. One unit has been decorated to stimulate the senses of people with dementia and has paintings of shop fronts, canals and trees and has recently had a “pub” with bar and piano. During the inspection residents on Primrose were seen to be walking freely about the unit taking an interest in their environment also making use of the garden area, with residents sat under the gazebo making craft items, others were enjoying the sun after their lunch. Netherton Green Nursing Home DS0000004886.V335218.R01.S.doc Version 5.2 Page 19 The home has an ongoing refurbishment programme. People can bring in treasured items from home with many bedrooms decorated with photographs, pictures and smaller times of furniture. There was a slight odour on windmill and some of the carpets on that unit were stained. The home has a variety of aids and adaptations such as grab rails assisted baths and a wheel in shower available for dependent service users and a full nurse call. Staff on Windmill said that they were unable to use all of the bathing facilities on the unit because service users were unable to access the bath in bathroom 5, this needed to be addressed, as at present they are only using two bathrooms for 27 people which is not idea. The home has some height adjustable beds for dependent residents. The home’s infection control procedures safeguard people from the risk of cross infection. Netherton Green Nursing Home DS0000004886.V335218.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has well trained and sufficient staff to meet service users needs. Recruitment and selection procedures are robust and safeguard the service users. EVIDENCE: Staffing levels generally meet residents’ needs. Residents did say that the staff are very busy and sometimes they had to wait but said: “ They always come as quick as they can though”. A resident on Saltwells also said that they were short staffed and she they frequently had to wait for attention at night. One member of staff in particular seemed to be working excessive hours, this was bought to the manager’s attention who was aware of the situation and said that she is managing it well with the cooperation of the member of staff. She sees her every day and visits her on the unit and asks questions about the service users and their care and takes note if the nurse if looking to tired. She will then reduce her shifts, the manager does this so that the nurse does not go and work at an agency where she would have no control over the amount of hours that she works. The home has 45 of care staff qualified to National level two qualification or above. Netherton Green Nursing Home DS0000004886.V335218.R01.S.doc Version 5.2 Page 21 Recruitment and selection of staff is conducted in a safe manner that safeguards service users, all staff files seen had appropriate checks i.e. Protection of Vulnerable Adults checks and Criminal records disclosures. All new staff have a two-day induction during which they are additional to care staff numbers. New care staff have also started to undertake the Skills for Care Induction although this could not be evidenced during the inspection. Netherton Green Nursing Home DS0000004886.V335218.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 good. This judgement has been made using available evidence including a visit to this service. New management arrangements, demonstrate that the home is well managed and has effective leadership, giving assurance that the health and safety of people who live at the home will be safeguarded. EVIDENCE: Netherton Green Nursing Home DS0000004886.V335218.R01.S.doc Version 5.2 Page 23 The home has a new Home Manager since April 2007 having been without a permanent Manager since November 2006. Sheila O’Connor is a registered nurse, with considerable experience at managerial levels within the NHS, private hospitals and has been a home manager at another BUPA home for more than three years. The Manager said that her application to be the registered Manager of the home with the Commission for Social Care Inspection (CSCI) would be sent to CSCI shortly. The Manager has the support of an Area Manager and within the home each unit has a Unit Managers, a Deputy manager is still to be appointed. The home does have a quality plan, which reviews all areas of the home at least annually. The home manager conducts monthly audits of the incidence of pressure sores and care plans and quarterly audits of accidents and complaints. A service user surveys are undertaken annually. A report is available of the findings of previous surveys. Staff can be rewarded customer service awards with “Personal Best Awards” which are nominated by services users or relatives for care beyond expectations and it was lovely to see a number of staff were proudly wearing their badges. Secure facilities are available for the safe keeping of residents’ personal money and valuables. Written records are available for all transactions and detail the reason for the withdrawal and two signatures. Regular external audits of service users personal money are undertaken. Services users are able to control their own finances if they want to and are able to, but the majority of services users have their finances managed by their families or by a Guardianship Order. Staff do not manage service users financial affairs as required by the regulations to safeguard services users financial interests. The home has good statutory training opportunities for fire safety training, moving and handling, infection control, the protection of vulnerable adults, first aid and health and safety. Procedures to protect service users include regular checks on the fire alarm, emergency lighting, fire extinguishers, nurse call points and hot water. The home has consistently demonstrated appropriate health and safety with support provided and audits undertaken by head office. The Manager confirmed that maintenance records and contracts were up to date. Netherton Green Nursing Home DS0000004886.V335218.R01.S.doc Version 5.2 Page 24 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 x 2 3 2 x 2 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Netherton Green Nursing Home DS0000004886.V335218.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5(1)(b) Requirement The home must ensure that terms and conditions in respect of the accommodation is supplied for service users. This will ensure that service users will have required information about the facilities provided within the fee. Service users must be weighed whenever possible at the time of their admission and thereafter regularly as required by their risk assessment. This will ensure that staff take required actions to promote residents health and well being. Timescale of the 31/05/06 not met. 3. OP9 13(2) The medicines of people who live at the care home must be kept safely. This will ensure that people’s medicines are safe and their health and wellbeing will be protected. 31/07/07 Timescale for action 30/09/07 2. OP8 15 31/07/07 Netherton Green Nursing Home DS0000004886.V335218.R01.S.doc Version 5.2 Page 26 4. OP9 13(2) When medicine is administered to people who use the service this must be clearly recorded. This will ensure that people receive the correct levels of medication. 31/07/07 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 Staff should ensure that service users discharge is comprehensively planned for including their needs in relation to medicines. A review of the suitability of equipment including beds and footstools should be undertaken. The registered person should ensure that staff are appropriately supervised on at least 6 occasions each year. 2 3 OP22 OP36 Netherton Green Nursing Home DS0000004886.V335218.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands Regional Office 1st Floor Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ 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 Netherton Green Nursing Home DS0000004886.V335218.R01.S.doc Version 5.2 Page 28 - 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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