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Inspection on 08/08/05 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 8th August 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 provides excellent sources of information for prospective and current service users alike and are welcoming to visitors to the site. The assessment process is extensive and completed thoroughly by staff, who use the information derived to develop care plans, which the service users or their representatives are included in their preparation and reviews. The home is well equipped to deliver nursing care and has robust safety procedures to ensure individual frailties are protected from harm. The whole site is well presented and maintained in very good condition with planned programmes to decorate and refurbish in a timely way.

What has improved since the last inspection?

Good progress has been achieved in addressing previous requirements and training for specific areas such as EMI has been given appropriate priority, preparing staff better for this area of work. Activities are presented in each unit in ways that make them appropriate to the client group in each unit.

What the care home could do better:

While as noted earlier the site generally is well presented it was clear that the short stay unit bedrooms appear comparatively stark compared to the other units and should be made more homely by an increase in decorative items and pictures. The buildings are designed and built to modern standards that don`t require the fitting of individual cold smoke seals to bedroom doors but it is considered that fitting of these is good practice. Hot water temperature to service user outlets is centrally controlled and requires systems that will ensure that following work on the system that the reset is confirmed as safe for delivery. In individual bedrooms the hand washbasins are equipped with liquid soap for staff to wash hands but not with dispensers for disposable towels. The home promotes the complaints procedure extensively but still a high proportion of relatives responded that they were not aware of it and therefore further effort is required to promote it. Unit managers should examine ways of staff working to reduce the impact of peak activity periods and seek to ensure an improved visibility of staff at these times.Some units have not made sufficient progress to ensure they individually have staff developed to NVQ level and may prevent the home as a whole achieving their 50% target by end December 2005. Similarly some units are not undertaking supervisions sessions for staff at a rate that will achieve the required 6 sessions over the year.

CARE HOMES FOR OLDER PEOPLE Netherton Green Nursing Home Bowling Green Road Netherton West Midlands DY2 9LY Lead Inspector Richard Eaves Announced 8 August 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Netherton Green Nursing Home Address Bowling Green Road Netherton, West Midlands, DY2 9LY 01384 410120 01384 413460 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BUPA Care Homes Limited Mrs Susan Dalwood Care Home 120 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (90), of places Physical disability (30), Terminally ill over 65 years of age (30) Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th January 2005 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. Each bungalow accommodates up to thirty service users. 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, there is also a quiet room with a sink and comfortable chairs which is also available for visitors. 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. Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an announced inspection undertaken by one inspector over two days during the summer 2005 and involved a full tour of each unit on site and included, the bedrooms, communal rooms and service areas. The Standards not inspected on this occasion will be included in the next inspection. The inspector had opportunity to speak with many service users and those able to communicate their views, were positive regarding all aspects of the home and care provision. Other information was gathered by observation, discussions with staff and records. Comment cards were received from 30 service users and 45 relatives/visitors to the home, 1 GP’s and 3 Care Manager. Service user comment card responses all but 2 expressed satisfaction with the care and support that they receive, the 2 said they felt well cared for only sometimes, all said they felt safe at the home. Areas with some dissatisfaction include 3 not liking the food and 7 sometimes, 6 indicated they would not know who to speak to if unhappy with care, 2 felt the activities were not suitable. Relative comment card responses were overall very positive about the home with all but 2 respondents confirming they were satisfied with overall care, 1 relative did not answer and 1 was not satisfied. Areas of concern include a view that there are not always sufficient staff on duty, one commented that this referred to Fridays; 18 persons said they were unaware of the homes complaints procedure while 24 were unaware of inspections and 16 about having access to the reports of inspection. Nineteen persons made additional comments these ranged from; “excellent” and “all is satisfactory, no problems, and the staff are very dedicated to concerns about staffing levels. One respondent identified that, “some staff did not understand about care and needed basic training ”. “ One commented that there needs to be more entertaiments2 respondents expressed concern at the delay in raising invoices” while 1 was concerned that two letters in respect of stolen items have not been acknowledged. One General Practitioner and three Care Managers returned comment cards and all gave very positive responses. The home functions calmly and efficiently under the leadership of individual unit managers and in conversation with the service users and in their comment card responses they confirmed that they were content with life at the home. Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 Page 6 What the service does well: What has improved since the last inspection? What they could do better: While as noted earlier the site generally is well presented it was clear that the short stay unit bedrooms appear comparatively stark compared to the other units and should be made more homely by an increase in decorative items and pictures. The buildings are designed and built to modern standards that don’t require the fitting of individual cold smoke seals to bedroom doors but it is considered that fitting of these is good practice. Hot water temperature to service user outlets is centrally controlled and requires systems that will ensure that following work on the system that the reset is confirmed as safe for delivery. In individual bedrooms the hand washbasins are equipped with liquid soap for staff to wash hands but not with dispensers for disposable towels. The home promotes the complaints procedure extensively but still a high proportion of relatives responded that they were not aware of it and therefore further effort is required to promote it. Unit managers should examine ways of staff working to reduce the impact of peak activity periods and seek to ensure an improved visibility of staff at these times. Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 Page 7 Some units have not made sufficient progress to ensure they individually have staff developed to NVQ level and may prevent the home as a whole achieving their 50 target by end December 2005. Similarly some units are not undertaking supervisions sessions for staff at a rate that will achieve the required 6 sessions over the year. 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. Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 - 6 The home provides good sources of information about the home and invites prospective service users to visit and spend time at the home prior to admission to enable them to make an informed decision about entering the home and receive a contract confirming the terms and conditions agreed for their stay at the home. The home uses comprehensive assessment tools, which means that residents’ needs are thoroughly assessed to ensure that care needs will be met. Introductory visits and trial stays are encouraged by the home, ensuring that people have time to make decisions, which are right for them. A dedicated team provide intermediate care that prepares service users to return home. EVIDENCE: Darby The unit has a copy of the homes statement of purpose that includes the units own philosophy, a copy of the service user guide was seen to be issued to each Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 Page 10 bedroom. All service users receive a contract at the point of admission and a copy is retained. A comprehensive assessment using the BUPA Minimum Data Set (MDS) and a range of risk assessments that identify needs and interventions required to address and minimise risks. One of the case files also included a behavioural assessment. Each of the assessments is subject to regular review although this process was not followed through to include a review of the minimum data set. Other assessment seen within the case files was that raised by the care managers at the point of admission and subsequent reviews. Prospective service users are given the opportunity to visit the unit prior to accepting a place at the home and the contract provides for a trial period. Primrose The unit has a copy of the homes statement of purpose that includes the units own philosophy, a copy of the service user guide was seen to be issued to each bedroom. All service users receive a contract at the point of admission and a copy is retained. A comprehensive assessment using the BUPA Minimum Data Set (MDS) and a range of risk assessments that identify needs and interventions required to address and minimise risks. One of the case files also included a behavioural assessment. Each of the assessments is subject to regular review although this process was not followed through to include a review of the minimum data set. Other assessment seen within the case files was that raised by the care managers at the point of admission and subsequent reviews. The sample of case files case tracked show the assessment process to be thorough. The unit invites prospective service users to trial the home and take care to carefully integrate new service users to the environment. Saltwells The unit has a copy of the homes statement of purpose that includes the units own philosophy, a copy of the service user guide was seen to be issued to each bedroom. This unit uses an assessment raised by the hospital that is received pre arrival at the home and a confirmation is returned that confirms the unit can meet the assessed needs. All admissions to this unit are for intermediate care and have a discharge strategy in place. Although a shortened process from the BUPA documentation the case files inspected show the assessments to be informative and completed thoroughly. Being an intermediate care provider, receiving service users direct from hospital there is no opportunity for service users to visit pre-admission. All aspects of the standard for intermediate care are met. Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 Page 11 Windmill The unit has a copy of the homes statement of purpose that includes the units own philosophy, a copy of the service user guide was seen to be issued to each bedroom. All service users receive a contract at the point of admission and a copy is retained. A comprehensive assessment using the BUPA Minimum Data Set (MDS) and a range of risk assessments that identify needs and interventions required to address and minimise risks. One of the case files viewed also included a behavioural assessment. Each of the assessments is subject to regular review although this process was not followed through to include a review of the minimum data set. Other assessment seen within the case files was that raised by the care managers at the point of admission and subsequent reviews. A sample of case files were case tracked and found that the assessment process was informative and identified needs individually relevant. Prospective service users are introduced to the unit by a number of visits to orientate and familiarise them with the home. Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 9 Health care needs of service uses are fully met and care planning in the home is overall of a good standard adequately guiding staff in the delivery of care needs. Medications are well managed at the home, facilitating the promotion of service users health. EVIDENCE: Darby A sample of case files were inspected and case tracked and were seen to include an extensive range of care plans to meet needs identified in the assessment process and providing clear guidance to staff on the delivery of care. One file include a care plan that had good direction to address contingencies that may arise due to specific conditions. The unit has a named nurse and named care key-worker for each service user and this is reflected in good care planning and completeness of recording. The unit has a good supply of pressure relieving equipment and there are no service users with pressure sores. Medication management is good and the unit uses a monitored dosage system for a large proportion of medicines. On the day of inspection the sharps bin Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 Page 13 was observed to be overfull and there was evidence of re-sheathing of used hypodermic needles. Primrose A sample of service users case files were inspected and case tracked and were observed to have a care plan for each assessed need and these plans gave clear direction for staff. One of the sample identified pressure damage and the care plan clearly identified nursing in bed on an appropriate mattress and the dressings prescribe to heal the condition. The case files show the involvement of allied medical services such as Optician, Dentist and Chiropodist. Medication is well managed within the unit with no problems identified during the inspection. Saltwells Care plans are clearly rehabilitative and are subject to at least weekly review and has good contingency planning and relevant to this acute setting. Medical care and direction is provided from the hospital supported by a GP out of hours service. Allied services to medicine are not frequently required but are arranged on an individual needs basis. Medicines are provided by the hospital with a 28-day supply the management of which is problem free. Evidence of re-sheathing of used hypodermic needles was observed. Windmill A sample of case files were selected at random to be inspected and case tracked. The care plans were seen to be drawn from the assessed needs process and were relevant and maintained to a good standard. Service users identified as at risk of pressure sores had good preventative measures in place and included an appropriate pressure relieving cushion for each identified need for a pressure relieving mattress. The unit manager identified that there is a plentiful supply to meet the needs of current service users. Medication is well managed within the unit with no problems identified during the inspection. Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 - 15 The home provides well-organised, varied and appropriate social and recreational activities that provide interest and pleasure for the residents. The visiting policy in each unit assists service users to maintain contact with their family and friends while also providing for the delivery of their care needs. Many aspects of care evidences that service users exercise choice and control over their lives. Meals at the home are wholesome and meet the nutritional needs of service users while reflecting choice and taste. EVIDENCE: The home has a 4-week rolling menu as well as a summer and winter menus. There are always choices available at mealtimes and residents can choose an alternative to the menu if they do not like any of the food choices off the menu, a hot alternative is included at each meal setting. Darby Life biographies are prepared for each service user that identifies preferred leisure and social interests. The hobby therapist maintains a record of the activities that service users participate in. Recent events have included a trip to the Safari park, dog petting, church service exercising and musical Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 Page 15 entertainments. The garden area has been well used over the summer and service users spoke of the pleasure of sitting out under the gazebo. The unit has open visiting and this was observed in practice with visitors coming and going freely during the morning. Personal preferences are recorded in the care notes regarding the frequency for bathing and their choice of a bath or shower and preferred time of rising and going to bed. In conversation with some service users it was clear that they were able to exercise these choices. Primrose Individual assessments are undertaken of activity pursuit patterns that include sleep pattern, rising and settling times and taking regard of known preferences and capacity for involvement in activities. Activity and stimulation needs are included in care planning and appropriate meaningful activities prescribed. The hobby therapist provides 30 hours of input to the unit a week providing group and individual input. There is currently a knitting group that a number of ladies were observed to be involved, the arts and crafts group produce a range of satisfying items such as hand made cards. Other activities include tea parties, sing-a-longs, entertainments and games. Regular outings are arranged such as shopping trips a visit to the safari park and a range of normal activities that the service users would have engaged in when at home such as pub visits. The home practices open visiting and a number of visitors were present during the inspection. Mealtimes are identified as an important part of the day and the meals are supplemented to ensure a high calorific value is achieved above the normal diet to meet increased nutritional needs. Choice for this group is achieved by showing the made up meal and allowing each to select. Saltwells The unit has a limited entertainment programme due to the concentrated rehabilitation programme. The staff provide group games, bingo and exercise sessions on a daily basis. The unit follows hospital visiting hours to provide for individual rehabilitation programmes to be under taken this policy is implemented flexibly and accommodates any special needs of family members. A main aim of the unit is to assist service users to regain independence and exercising choice is recognised as an important part in this to achieving selfmotivation. The service users spoken with were happy to be in the unit and out of hospital and a number specifically complemented the meals as being excellent and in particular the cooked breakfast having had continental style while in hospital. Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 Page 16 Windmill The unit has the input of an activities organiser for 6 hours each day to provide activities such as arts and crafts and games, exercising and singing on a daily basis. Entertainments are frequently provided and dog petting sessions are provided and are said to be a favourite among the service users. Trips out such as to Stourport and shopping are organised regularly. Families are welcome at any time and encouraged and assisted to participate in the life of the unit. During the inspection one service user went out for the day with family. Service users are enabled to personalise their bedrooms if they wish with photographs and possessions such as ornaments and furniture. While acknowledging the limitations for service users they are assisted and encouraged to exercise choice and control over their lives within their capability. Mealtimes are identified as an important part of the day for service users, which continues to give a great deal of satisfaction and staff report that they eat their meals with enthusiasm. The meals provided are supplemented to ensure a high calorific value is achieved above the normal diet to meet increased nutritional needs. Choice for this group is achieved by showing the made up meal and allowing each to select. The 30 service user comment cards received had responses to activities provision and meals with some degree of negativity, 2 respondents thought that activities were not suited to them while 3 did not like the food but 7 others qualified liking the food as only sometimes. Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 17 The home complaints policy is robust providing a safe environment in which service users feel they can voice concerns and that these will be listened and responded to. Service users rights are protected and advocacy services are promoted which contributes in providing access to services and representing their views. EVIDENCE: The home has a detailed complaints procedure, which is displayed in each of the units and also included in the service user guide. Service users spoken with said if they had any concerns they would not hesitate to discuss them with the unit manager. Of 30 comment cards received from service users 6 responded that they would not know who to speak to if unhappy with care. Of 45 relative responses, 18 said they were not aware of the complaints procedure. One complaint has been received since the last inspection and this was resolved at a local level to the satisfaction of the complainant. Advocacy services both locally and condition specific services, such as the Altzeimers Society are promoted. The EMI units have very active relatives groups. Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26 The environment of the home is maintained to a good standard, clean and hygienic providing the service users with a comfortable and safe place in which to live. EVIDENCE: Netherton Green Nursing Home is a purpose-built property, providing accommodation for up to for 120 persons requiring nursing care in 4 bungalow units of 30 single bedrooms. The home continues to be refurbished, redecorated and repaired on an ongoing basis. The décor, fixtures and furniture are generally completed to high standards. The home has extensive grounds with each unit having its own garden area. Ample car parking is provided. Each unit was toured during the inspection and individual findings follow. Hot water is centrally controlled and on the first day was found to be set to high and was adjusted immediately. The units follow the same design providing bedrooms with a hand wash basin, furnished with good quality furniture including a proportion of nursing beds. Heating is by low surface temperature Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 Page 19 radiators, lighting is overhead and bedside, ventilation is natural from restricted opening windows and a staff call system is available in all service user areas. Individual bedroom doors are not fitted with cold smoke seals. The units are each fitted with two sluice disinfectors. Each of the units were found to be clean and odour free and have a cleaning schedule that details when and how cleaning is done ensuring clean and hygienic environments. Darby The unit was found to be clean and in good decorative order, the bedrooms visited were personalised and reflect the occupants likes and wishes, 3 rooms have adjustable nursing beds. Liquid soap for staff use is provided in each bedroom but no disposable towel dispenser. Primrose This unit was clean and free from odours with good decoration, some of the bedrooms were personalised with ornaments and photographs. Saltwells The unit is programmed to be refurbished this year however if looking a bit worn was clean, hygienic and free from unpleasant odours. A number of extractor fans were not working on the day of inspection and as in other units the hot water was delivered at too high a temperature. Being a short stay unit the individual rooms appeared not to be personalised and stark and would benefit from pictures on the walls. Windmill This unit was clean and free from odours with good decoration, some of the bedrooms were personalised with ornaments and photographs. As in other units the hot water was delivered at too high a temperature. The home has a large well equipped laundry provided centrally meeting all requirements of the standard. Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 & 30 Good progress has been made over recent years in creating a stable mix and number of staff ensuring service users receive consistency of care. The home continues to make progress in developing a skilled staff group with understanding of service users needs. EVIDENCE: Staff are appointed and allocated staff to each of the 4 units to provide consistency and in such numbers that reflect the dependency needs of the service users. Details of daily allocations are shown under each unit heading. Of 45 comment cards returned 11 thought that there are not always sufficient staff but those that commented were complementary about the dedication and hard work of the staff. Induction and foundation training is to TOPPS standards and the records show that new staff have attended induction sessions. Mandatory training is provided such as fire safety, moving and handling, basic food hygiene, health & safety, the protection of vulnerable adults and whistle blowing. Staff training files are held on each unit with a master matrix held centrally. Darby Staff are allocated with a Nurse leading each shift supported by 5 carers in the morning, 4 carers during the afternoon and early evening and 2 carers at night. Staff spoken with said that the numbers were adequate to meet the dependency needs of the current service users. Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 Page 21 The unit has 14 of 15 carers with an NVQ at level 2 and all staff are included in BUPA’s Personal Best training scheme which most have almost completed. Primrose Staff are allocated on the basis of 2 Nurses between 8 am and 4 pm and 1 Nurse thereafter. Carers are allocated, 5 am, 4 pm and 2 at night. The unit currently have 6 carers holding an NVQ at level two with 9 enrolled and expected to complete shortly, which will exceed the 50 target prior to the end of year target. In addition to mandatory training all staff receive training in understanding dementia and undertake the BUPA personal best. Saltwells This unit is staffed to acknowledge the high level of activity created by the intermediate care arrangement. Allocations are 2 Nurses during the day and 1 at night reflecting that no admissions are accepted after 8pm. Carer allocation is 6 am, 4pm and 3 at night. During the day there is also involvement of Trust rehabilitation staff of Occupational therapists and Physiotherapists. This unit currently have 6 carers with NVQ level 2 and anticipate reaching the 50 target by end of December. The unit meets the mandatory training requirements and has 7 first aiders, the manager has attended the fire trainers course. Windmill Staff are allocated to the unit on the basis of 1 Nurse over the 3 shifts and 6 carers in the morning, 4 pm and 2 at night, the unit manager overlaps the morning and afternoon shifts, providing 2 nursing staff over a large part of the day. The unit is making good progress in achieving 50 of staff with NVQ having 8 of 20 carers with it and 5 further due to complete. Staff all attend their mandatory training and 5 hold a first aid certificate, carers participate in the BUPA personal best training and a number have attended training in nutrition, risk assessing and COSHH. Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 Staff receive supervision and direction but not frequently enough to ensure that the service users will receive consistent quality care. EVIDENCE: A system of formal supervision and appraisal has been implemented across the full site with all units having made initial appraisals and least one supervision for most staff. Some units are further progressed than others and can be seen to be well progressed to achieving the required 6 over each year. Darby This unit has issued its documentation system appraised all staff and commenced the supervision process. Discussion about progress and how the standard will be achieved fully as this will now requires a concentration of the time span between sessions. Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 Page 23 Primrose This unit has its programme of supervisions well established with good documentary records. Recording by staff are patchy and staff could be further supported and developed to maximise what they get from the sessions. Saltwells This unit has taken on supervision enthusiastically and are making good progress in meeting the target of 6 sessions. The content of the sessions are appropriate covering aspects of delivering care within the philosophy of the unit. Windmill This unit has not progressed supervisions but has raised a folder for each member of staff, undertaken and appraisal for each of them and started to undertake supervisions of the day staff. Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 2 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x x x x x x 2 x x Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard op9 Regulation 13(2) Requirement The registered person must take action to stop the practice of resheathing used hypodermic needles. The manager must ensure that those rooms occupied on a short-term basis through the intermediate care arrangement are decorated with pictures and ornaments to give the rooms a homely feel. The responsible person must ensure service users are safe from cold smoke by fitting seals to bedroom doors. The registered person must ensure the programme of refurbishment and redecoration continues. The responsible person will ensure that hot running water is distributed safely to service users at 43°C at all times. The registered person will ensure that disposable towells are made available at all staff handwash areas. The registered person must prepare a report and action plan demonstrating how the standard of 50 of care staff will be Timescale for action 31/10/05 2. op19 16(2)(c) 31/10/05 3. op19 23(4)(c) 31/12/05 4. op19 23(2)(d) 31/3/05 5. op26 13(3) 31/10/05 6. op26 13(3) 31/10/05 7. op28 18(1)(a) 31/10/05 Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 Page 26 8. op36 18(2)(a) qualified at NVQ level 2 in care by the target date of 31.12.2005 The registered person must ensure that staff are appropriately supervised on at least 6 occassions each year. 31.3.06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard op3 op12 op15 Good Practice Recommendations It is recommended that the regular reviews of assessments be expanded to include the minimum data set of information. It is recommended that unit managers ensure that activities are inclusive for all or provision be identified for those who decline group activity. It is recommended that the home takes not of the comments returned to the Commission that 1 in 3 were not wholly satisfied with meals at the home. Netherton Green Nursing Home E55 S4886 Netherton Green V237189 080805 Stg4.doc Version 1.40 Page 27 Commission for Social Care Inspection Mucklow Office Park West Point, Mucklow Hill West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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