Inspection on 08/06/06 for Nettleton Manor

This inspection was carried out on 8th June 2006.

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

Nettleton Manor 16/04/07

Nettleton Manor 07/02/06

Nettleton Manor 06/05/05

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

CARE HOMES FOR OLDER PEOPLE Nettleton Manor Moortown Road Nettleton Caistor Lincs LN7 6HX Lead Inspector Mr David Bacon Key Unannounced Inspection 8th June 2006 08:30 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 Nettleton Manor DS0000064035.V297969.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. Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nettleton Manor Address Moortown Road Nettleton Caistor Lincs LN7 6HX 01472 851230 01472 852015 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) Hapee Care Ltd Mrs Elizabeth Maude Alexander Smith Care Home 41 Category(ies) of Dementia - over 65 years of age (41), Old age, registration, with number not falling within any other category (41), of places Physical disability (4) Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service users in the category of Physical Disability must be aged 50 years and over. The Home is registered to provide personal care, with nursing, for service users of both sexes whose primary needs fall within the following categories: Old age, not falling within any other category (OP) - 41 Dementia - over 65 years of age (DE(E)) - 41 Physical disability ({PD) - 4 The registered manager undertakes training to obtain the Registered Managers Award, and should enroll on the training within three months of registration. The registered manager undertakes a recognised training course in the management of dementia needs within three months of registration. The maximum number of service users to be accommodated is 41. 3. 4. 5. Date of last inspection 7th February 2006 Brief Description of the Service: Nettleton Manor is a two-storey, Victorian manor house property standing back from the road in four acres of woodland and gardens, in the village of Nettleton near the towns of Caistor and Market Rasen. There are no shops within walking distance although the home is on a bus route to Caistor and Market Rasen. The home consists of twenty-one single and ten shared rooms, thirteen of which have an ensuite toilet or bathroom. The home has three residents’ lounges and one dining room. A ‘chapel’ is being created as a quiet area for communal or individual use. There are three bathrooms and several toilets situated near to residents rooms and communal areas. A passenger lift gives access to the upper floor although some rooms upstairs are only available to residents without limited mobility. There is a large garden to the rear of the property, which is accessible for residents, and a large car park for visitors. The range of fees is between £335 and £464 each week. Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit took place over 5 hours; it was unannounced and was carried out by one inspector. A tour of the premises was conducted, service users care records and staff records were inspected. The inspector spoke with three service users, two service users representatives, the registered manager of the home and six staff members. Fifteen service users and representatives had completed quality satisfaction questionnaires regarding the care home, which were received prior to the site visit. What the service does well: What has improved since the last inspection? What they could do better: The homes medication system is not adequately maintained as medicines are not correctly receipted into the building or as administered. Much of the physical state of the premises in need of refurbishment although all areas are clean and tidy. Emergency lighting tests were not fully completed as per fire safety regulations. Service users are not fully supported to express their views regarding the care they receive. For example, residents meetings and quality satisfaction questionnaires. Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 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. Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 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 the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are satisfactory procedures in place for the introduction of residents to the home. EVIDENCE: The service users and representatives spoken with confirmed that they were satisfied with admission arrangements. Comments included: “It was all done very well, with caring staff to help”. “They did what they could, you don’t want to move from home but they were very caring”. “Oh, yes, they were very welcoming and always are, it doesn’t change” The service users care records viewed identified that an assessment of each service users care needs had taken place, which included an assessment of risk and how these were to be minimised. Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 Page 9 The care plans seen were updated regularly and service users, or their representatives are consulted with regarding the care plan where this is possible. Service users are provided with written terms and conditions of residence contracts and signed copies are maintained on the premises. Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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. There are adequate arrangements for meeting resident’s health care needs although medication systems must be improved to ensure that medication procedures are safe. The service users spoken with are treated with respect and satisfied with the care provided. EVIDENCE: The fifteen service users satisfaction questionnaires received prior to the site visit indicated that service users were satisfied with how they were treated and the care provided. The service users and representatives spoken with confirmed that they were satisfied with how residents were treated by staff but concern was expressed that staffing numbers had been reduced, which is addressed within the staffing section of this report. The care records viewed identified service users care needs and documented how these were to be met. For example, two service user had been admitted Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 Page 11 to the home having pressure sores and their records documented these care needs and instructed staff as to how these were to be cared for. The care records seen had been updated each month but did not document where service users, or their representatives had been consulted with regarding their plan although it is acknowledged that both service users had recently been admitted. The two care staff spoken with were aware of the service users care needs. Medication is appropriately stored although the records viewed did not evidence that medicines are receipted as received into the home or as administered. Staff whom administer medicines receive training regarding this. Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to maintain and develop community links as they prefer and regarding the care they receive. The overall provision of meals and activities are enjoyed by service users. EVIDENCE: The service users satisfaction questionnaires received prior to the site visit indicated that service users were generally satisfied with the meals and activities provided and no suggestions for improvement were made. The service users and representatives with whom the inspector spoke further supported these views. Comments included: “Yes, the food always seems fine, no problems that I’m aware of”. “The food is good and often home made”. “I’m quite happy with the food”. “I’m not sure there is a choice but it tastes good”. A four-week menu is in place, which is varied and an alternative is available at each meat time although the service users spoken with were not fully aware of this. Food and storage temperatures are maintained. Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 Page 13 The service users and representatives spoken with confirmed that service users are able to spend their time as they liked and that visitors are made welcome. Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are satisfactory procedures in place overall to ensure that service users are protected and they can raise concerns should they wish to. All staff are not fully aware of the homes abuse and whistle blowing policies and procedures, which may place service users at risk. EVIDENCE: The home has a whistle blowing policy and adult protection and abuse awareness policies and procedures are in place along with abuse awareness training although not all of the staff spoken with were not fully aware of the correct procedures required to be taken in the event of an issue of abuse being identified. Complaint policies and procedures are in place and information regarding these is provided to service users and displayed in the home. No complaints have been received by the CSCI since the last inspection. The home received one informal complaint and it is understood that this was resolved to the complainant’s satisfaction. Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 19, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvements are being made regarding the physical state of the premises although the home is kept sufficiently clean and tidy. EVIDENCE: The home was clean and tidy throughout although many areas are in need of refurbishment. For example, the double-glazing in the new wing has blown, there is a significant number of ceiling and wall cracks on the first floor and the majority of service users bedrooms and some communal areas are in need of re-decoration. It is acknowledged that two service users bedrooms have recently been refurbished and a new roof has been fitted. The service users and representatives spoken with were satisfied with the physical environment. Comments included: “It does all look a bit worn but you Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 Page 16 don’t mind so much as long as there are enough staff and the care is good”. “It’s clean and homely”. Hot water temperatures are now monitored on a regular basis, and a risk assessment for the prevention of legionella has been conducted. Separate cleaning staff are employed. Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Recruitment procedures are robust although there is an insufficient number of care staff deployed to appropriately care for service users. Staff receive some induction and are provided with sufficient training to enable them to meet the needs of service users. EVIDENCE: Several comments received from some service users, representatives and staff members spoken with said that the homes care staff met service users individual care needs but that care standards had deteriorated to an unacceptable standard due to staffing numbers being reduced. The home rota was seen which further evidenced this. For example, one qualified staff member is on duty at all times although care and kitchen staff numbers have been reduced. It is understood that some action has been taken by the home management to address the reduction in care staffing levels. This matter must be addressed. The staff records viewed were well maintained overall and evidence that appropriate recruitment procedures had been followed. The staff members spoken with confirmed that they had received some induction and sufficient training to enable them to carryout their roles. Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 Page 18 Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. 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. The service users are satisfied overall with the standards of care and the management of the home and their financial interests are safeguarded. The health and safety of service users is promoted overall but they are not fully supported to express their views regarding the overall running of the home. EVIDENCE: Risk assessments have been completed for all service users and for the overall safety of the premises. Some systems are in place to minimise risks to residents prone to wandering, which includes the fitting of door locks and the manager said that alarms or keypads are due to be fitted for general Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 Page 20 convenience of service users, visitors and staff. Maintenance records are kept and made available for inspection. The home refrain from involvement in service users finances where possible although safeguards and records are in place where this occurs. The service users and staff members spoken with were satisfied overall with the manager’s approach to the role. Comments included: “I like the home, they all treat you well”. “It’s very family like here, honestly, the staff are really very good”. “The manager is approachable, I am settled here”. Residents meetings are not held and quality satisfaction questionnaires are not sent to service users. The fifteen completed satisfaction questionnaires sent to CSCI as part of this inspection evidenced that service users overall were satisfied with the services provided by the home. The staff attend statutory training of which records are maintained. The staff members spoken with were aware of safe practices, they attend training regarding this and policies and procedures are in place. Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 Page 21 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 Page 22 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) Timescale for action The registered person shall make 08/06/06 arrangements for the recording, handling and safe administration of medicines. Therefore, all medicines must be signed for as received into the home. An up to date copy of the revised 31/07/06 Adult Protection procedure must be in place and staff must attend training regarding abuse awareness. Fire safety tests must be 30/06/06 undertaken as per the Fire Safety Officers instructions. All areas of the home must be 31/07/06 clean and reasonably decorated and in a good state of repair. Therefore, an action plan is required detailing what action is being taken to improve the physical state of the premises including blown window areas, service users bedrooms, communal areas and hallways. Sufficient numbers of care staff 30/06/06 must be deployed at all times. Requirement 2 OP18 13 (6) 3 4 OP19 OP19 23 (4) 23 (2) (b) (d) 5 OP27 18 (1) (a) Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 Page 23 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 OP15 Good Practice Recommendations It is recommended that service users are further informed of the food choices available at each mealtime. Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Nettleton Manor DS0000064035.V297969.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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