Inspection on 09/06/05 for Netherwood

This inspection was carried out on 9th June 2005.

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

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

Other inspections for this house

Netherwood 22/05/07

Netherwood 18/10/06

Netherwood 22/11/05

Netherwood 09/11/04

Netherwood 24/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Netherwood Haughton Village Shifnal Shropshire TF11 8DG Lead Inspector Keith Salmon Announced 9 June 2005 09:00 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. Netherwood CS0000020718.V205036.R01.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Netherwood Address Haughton Village Shifnal Shropshire TF11 8DG 01952 462192 01952 462494 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) David Harrison and Ann Harrison Mrs Hazel Ann Ridley Care Home 31 Category(ies) of 31 x Old age, not falling within any other registration, with number category (OP) of places Netherwood CS0000020718.V205036.R01.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 31 older persons can be accommodated which can include a maximum of 3 over the age of 65 with dementia. Date of last inspection 9th November 2004 Brief Description of the Service: Netherwood is a Care Home Registered with the Commission for Social Care Inspection to provide accommodation and personal care for a total of 31elderly people. The Home is in the village of Haughton, on the outskirts of Shifnal. Set back from the road, in its own grounds, the Home enjoys a peaceful location, where views of the surrounding countryside can be enjoyed from most aspects of the building. The accommodation comprises an original building, which has been adapted and extended, with the additional provision of a 10bedded Unit in 2002. Bedrooms, of which 19 offer single accommodation and 6 shared double accommodation, are situated on two floors serviced by 2 passenger lifts. All areas are maintained and furnished to a high standard, providing welcoming and comfortable surroundings. The grounds are laid to lawn, with mature trees and shrubs flower borders and garden seating to enable Service Users, of various physical abilities, to enjoy them. Netherwood CS0000020718.V205036.R01.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced Inspection commenced at 09.30, lasted 6.0 hours and was undertaken by one Inspector. This Report is a product of observations made during a tour of the Home, discussions with the Proprietor, Manager and Staff, plus a review of care related documentation, including staff recruitment/ deployment records and a range of documents/records reflecting the general operation of the Home. Discussions were held with 9 Residents and several members of Staff. Previously held high standards of direct care provision, and overall management have been maintained, and carried out in, what is clearly, a very friendly and open atmosphere. This is strongly reflected in nine ‘comment cards’ received from Residents, thirteen from Relatives and six from visiting clinical professionals. Written comments included… “Exceptionally committed and caring staff, well led and motivated…”, “...level of commitment to training and development is high…”, “…The Staff are always available and appear to make great efforts for those in their care…”, “…My Mother is taken out regularly and is happy with her stay…” ”…I enjoy my food. I have just what I like – it’s like a posh hotel. I have been a Resident for many years, and I love it…” What the service does well: What has improved since the last inspection? What they could do better: Judging by the verbal and written comments, made by Residents and their Visitors, together with observations during the Inspection, there appears nothing of significance to which the Home could turn their attentions, over and above that which they are currently doing, as all aspects of care provision are of excellent quality. Netherwood CS0000020718.V205036.R01.doc Version 1.30 Page 6 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. Netherwood CS0000020718.V205036.R01.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Netherwood CS0000020718.V205036.R01.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 and 5 Prospective Residents are enabled to reach an informed choice, and to fully understand the service they can expect, prior to taking up residency. Prior to admission, processes to ensure appropriate, thorough and effective care needs assessment are diligently undertaken and applied. Staff are enabled to provide the type, and quality of care, required by Residents. EVIDENCE: The Home has a Statement of Purpose and User Guide, both of which are concise and easy to read, with content that meet the requirements of the Standard. Service Users are provided with a Statement of Terms and Conditions detailing the accommodation to be provided. Evidence from 10 randomly selected Care Plans, and discussions with Residents and their Relatives, clearly showed the Registered Manager, or Deputy Manager, assess all prospective Residents/Service Users prior to admission and new Residents have the opportunity to visit the Home, or enter the Home on a trial basis, prior to admission. Netherwood CS0000020718.V205036.R01.doc Version 1.30 Page 9 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) 7,8,9,10 and 11 The model of Care Plan utilised by the Home is of an excellent design, which is diligently and effectively utilised in aiding the provision of care, pertinent to Residents’ assessed care needs. Staff relate to Residents and their families / visitors in a friendly, respectful, and when needed, supportive manner. The storage, administration and disposal of medicines are fully in accordance with accepted good practice. EVIDENCE: Care Planning documentation was well organised, current, clearly written and comprehensively encompassed the range of ‘care areas’ necessary to ensure the delivery of care appropriate to the needs of each Resident. Operational Policies and Procedures were reviewed found to be up-to-date and comprehensive. All accidents/incidents, however minor, are recorded in the Accident Book, with action and outcome, and none proved of particular concern to the Inspector. Inspection of medicine storage provision, and administration records, demonstrated the Home’s practices meet the guidelines of the Royal Pharmaceutical Society. There is ‘in-house’ training in helping recently bereaved Relatives, and other Service Users, and this aspect of care is handled in a sensitive manner. Netherwood CS0000020718.V205036.R01.doc Version 1.30 Page 10 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) 12,13,14 and 15 A range of leisure opportunities, consistent with Residents’ capabilities, is provided, and the Home facilitates achievement of desired lifestyle, through Residents conducting the pattern of their day as they wish. This includes contact with family and friends, and continuation of religious practices. The Home provides a daily choice of attractive and nutritious meals for which Catering Staff are to be commended. The Home is well integrated into the Community and its’ activities. EVIDENCE: The Home has a very full programme of activities, which is planned and organised by a ‘Social Therapist’, who attends the Home on three half full days per week. The programme is up-dated on a monthly basis, and posted on notice boards around the Home. Activities include local trips with relatives, visits to local garden centres, preparation work for the Homes ‘float’ at the local carnival and involvement in commemorative events, e.g. ‘V.E. Day’ celebrations. At the time of the Inspection several of the Service Users were involved in making ‘greetings’ cards for various occasions. In addition, the Home utilises input from several volunteers, e.g. two people, who cover four sessions per week, playing cards and dominoes with the Residents. These individuals, one of whom the Inspector met, seemed appropriately supported and were clearly in addition to ‘regular’ Care Staff numbers. Netherwood CS0000020718.V205036.R01.doc Version 1.30 Page 11 An interesting aspect of daily social activity is Residents regularly queue to accompany the Home’s Owner/Maintenance Man on his visits to local suppliers, and a number of Residents told the Inspector how much they looked forward to and enjoyed this outing. The Home is to be commended for their continued approach to providing activities for Residents to enjoy. Residents were very complementary about the quality of meals and the choices they are afforded. Netherwood CS0000020718.V205036.R01.doc Version 1.30 Page 12 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 and 18 The interests of Residents are protected through ready access to the Home’s Complaints Procedure and information relating to advocacy services. Staff are clearly aware of their role in protecting Residents from abuse. EVIDENCE: A clear and concise Complaints Procedure is displayed in the main hallway, which includes reference to the Commission for Social Care Inspection as the regulatory body, together with contact details. Information relating to the use of advocacy services is also displayed. Policies relating to the protection of Residents from abuse were observed to be in place and readily accessible, these included, ‘Whistle Blowing’, ‘Abuse Awareness’ and ‘Adult Protection’. Staff training files indicated that Staff had received training in respect of these Policies. The Home maintains a meticulous system for recording complaints, though none having been lodged since the previous inspection. Residents, who wished to, were enabled to vote at the recent General Election. Netherwood CS0000020718.V205036.R01.doc Version 1.30 Page 13 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) 19,20,21,22,23,24,25 and 26. The Home’s lounge/sitting and dining areas offer a good variety of size and outlook, with furnishings being in good order and presenting a ‘domestic’ ambience. Specialist equipment is available to facilitate provision of care, e.g. hoists, wheelchairs, stand-aids, is consistent with the needs of the Service Users, and with the demands of tasks carried out by Care Staff. The gardens provide a safe environment, easily accessible to Service Users at all times of year. The standard of cleanliness in the Home is excellent. EVIDENCE: The Home has a full range of maintenance contracts in place, and an on-going refurbishment/redecoration programme. The garden, which has level paved areas enabling easy walks or wheelchair use, has recently been improved following the replacement of two gates, plus alterations to fencing adjacent to a neighbouring field. This is to ensure the garden is more ‘secure’, particularly for Resident’s with confusional disorders. The Home continues to be maintained to the very high level of decor and general repair observed at previous Inspections. The Home has weekly attendance from a Chartered Physiotherapist, who, in addition to providing direct professional input to Netherwood CS0000020718.V205036.R01.doc Version 1.30 Page 14 individual clients within the Home, is also able to give advice on the overall suitability for purpose of the premises, and of in-house specialist equipment. Bedrooms are comfortably furnished, and equipped to a high standard and Residents are clearly encouraged to personalise bedrooms with their own possessions. The Inspector considers the Home has exceeded the requirements of the Standard through the provision of extra facilities, e.g. additional bedroom storage space, and the purchase of some extra items of bedroom furniture for rooms occupied by Residents unable to bring their own items into the Home - the choice of individual items being made with the Resident concerned. The laundry is well organised with a large washing capacity provided by an industrial sized machine, with a plumbed-in detergent and fabric conditioner supply, thus eradicating mess and providing good health and safety practice. There is a well-organised system for ensuring personal clothing is returned to the respective Service User. The cleanliness and general state of repair in all areas of the Home is a credit to the Housekeeping and Maintenance Staff. Netherwood CS0000020718.V205036.R01.doc Version 1.30 Page 15 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) 27,28,29 and 30. Staff numbers and skill-mix on duty were consistent with that shown on the rota, and were sufficient to meet the assessed care needs of current Residents. Recruitment and employment practices are consistent with the safeguarding of Residents. The commitment of the Home to providing training for Care Staff is exemplary. EVIDENCE: The current staffing rota, and those from the immediately preceding weeks, were examined. Staffing numbers and skill-mix enable a service provision, which meets the care needs of the Service Users. In addition, when judged necessary by the Manager, e.g. periods of peak activity and/or increased dependency, funds are available to increase staffing to meet those needs. Staff Personal Files demonstrated evidence of full compliance with the Standard and Schedule 2 of the Regulations. Staff are subject to a thorough, and relevant, orientation/induction programme, which is followed by comprehensive ‘foundation’ training, e.g. ‘manual handling and lifting’, ‘fire safety’, ‘simple infection control’. In addition, the Home enjoys an excellent record for the continuing development of Care Staff, and supporting Staff in undertaking appropriate training based on a well-structured plan for determining individual training needs. The current very high level of NVQ Level 2 attainment (73 of Carer Staff) reflects a very positive approach to enabling skills development, and is seen in the opportunity afforded to 6 Care Netherwood CS0000020718.V205036.R01.doc Version 1.30 Page 16 Staff to undertake ‘Second Chance English’ classes leading to an English GCSE examination, and helping staff to improve their report writing skills. Arising from a proposal to increase the number of Residents categorised as having ‘dementia’ (from 3 currently to 6), Care Staff are to commence a 16-week course in the ‘Care of Residents with Dementia.’ The Inspector considers the Proprietors/Management are to be commended for their continued commitment to staff training. Netherwood CS0000020718.V205036.R01.doc Version 1.30 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36,37 and 38. The Home has excellent leadership from the Manager who is very well supported by the Owners. The ambience of the Home is warm, friendly and inclusive. Operationally, the Home is very well organised, with the central purpose being ‘the best interests of Residents’. Lines of accountability are clearly set out and observed. Staff are subject to effective support with regular ‘supervision, and appeared involved and happy in their work. Accounting and financial procedures are conducted and recorded efficiently. EVIDENCE: The Registered Manager has many years experience as a Care Manager, the past 9 years gained in her current post at Netherwood, and has recently successfully completed the NVQ Level 4 (Management) qualification. The Inspector observed Residents and Staff were able to approach the Registered Manager with a range of issues, which were received in an interested and involved manner. Quality assurance is monitored by the frequent implementation of questionnaires circulated to Service Users, with responders Netherwood CS0000020718.V205036.R01.doc Version 1.30 Page 18 being both named and anonymous. Completed questionnaires are also received from outside parties, e.g. relatives, friends, clinical service specialists and Social Services Staff. The Home’s Quality Assurance Plan is reviewed annually. The Home conducts financial management of personal monies for two Service Users and records of transactions are maintained in accordance with all requirements of the Standard. All other records were seen to be secure and well maintained. The Home’s practices in the context of health, safety and welfare of Residents, Visitors and Staff were seen to be in accordance with the Regulations. Netherwood CS0000020718.V205036.R01.doc Version 1.30 Page 19 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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION 4 4 3 3 3 4 4 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 4 4 3 3 3 3 3 3 Netherwood CS0000020718.V205036.R01.doc Version 1.30 Page 20 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 Regulation Requirement There are no Requirements arising from this Inspection Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Netherwood CS0000020718.V205036.R01.doc Version 1.30 Page 21 Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn SHREWSBURY SY2 5DE 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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