Inspection on 28/02/07 for Neva Manor Residential Care Home

This inspection was carried out on 28th February 2007.

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

Neva Manor Residential Care Home 14/11/07

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Neva Manor Residential Care Home 4 Neva Road Weston Super Mare North Somerset BS23 1YD Lead Inspector Pippa Greed Unannounced Inspection 09:30 28 February 2007 th 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 Neva Manor Residential Care Home DS0000068269.V321973.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. Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Neva Manor Residential Care Home Address 4 Neva Road Weston Super Mare North Somerset BS23 1YD 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) 01934 623413 01934 623413 Mr Dharma Rajoo Bungaroo Mrs Devianee Bungaroo Kimberly Neale Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate one service user aged less than 65 years of age, as named in CSCI letter dated 19.09.06 New service Date of last inspection Brief Description of the Service: Neva Manor Residential Care Home is a large Victorian house situated in a quiet residential road in Weston-Super-Mare and close to the seafront. The town centre is nearby with a range of shops and recreational activities. The home is registered to provide residential care for up to 14 older persons in a converted property. The accommodation is situated over two floors with a chair lift and stairs for accessing the upper floor. A lounge and dining area is situated at the rear of the property and there is an additional quiet lounge situated at the front of the home. Mr & Mrs Bungaroo own Neva Manor and registered with the Commission in September 2006. Ms Kimberley Neale is the registered manager. The current fee levels are between £336.65 and £405.39 per week. Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over the course of one day (8.5hrs) on 28th February 2007. It was conducted by Pippa Greed, Regulation Inspector. Thirteen service users were living at the home. The inspector spoke to four service users, three staff, and one visitor visiting the home. The inspector was also assisted by the manager throughout the inspection process. A tour of the premises was made and the service users were seen and spoken with, both in the communal areas and in private in their rooms. The inspector observed daily living and care provided in the home including lunchtime routine. Four service users care plans were selected for case tracking. As part of the inspection process the inspector used ‘case tracking’ as a means of assessing some of the national minimum standards. This process allowed the inspector to focus on a small group of people living in the home. All records relating to these people were inspected, along with the rooms they occupied in the home. Four staff files were checked and documents related to the running of the home were examined, such as medications administration records and maintenance checks. Ms Kimberley Neale is the registered care manager. She is supported by one deputy and one senior care assistant. Mr Dharma and Mrs Devianee Bungaroo are the registered providers. Pre-Inspection Questionnaire was not received by the CSCI. Surveys were sent out to three relatives, and three General Practitioners. All the comments received from service users on the day of the inspection were complimentary about the home and included comments such as ‘They are so kind here. They do everything to help me’, ‘We are 100 looked after’ and ‘Staff are wonderful.’ The inspectors would like to thank the service users, staff and the manager for their hospitality and assistance with the inspection process. What the service does well: Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 6 Neva Manor provides a very homely ‘family feel’ environment for service users. There is an extremely relaxed atmosphere where service users are supportive of one another and also staff and management are open and approachable. Service users are encouraged to exercise choice and control over their lives and maintain close contact with their families, friends and the local community. They are able to enjoy activities and the home provides a caring and cheerful atmosphere. The food served at the home is of good standard and service users are very satisfied with the quality of food available. Service users commented ‘The food is mixed and varied’. The routines in the home are flexible to suit the needs and wishes of the service users. People are free to choose when they get up, when they go to bed and how they spend their day. Many of the service users at Neva Manor chose to live here with support from family and friends. All service users spoken to were extremely complimentary about the staff that worked in the home. Staff were described as kind and always ready to listen. The inspectors observed that staff spoke to service users in a warm and respectful manner. What has improved since the last inspection? What they could do better: Four requirements and five recommendations were made at this inspection. Four staff recruitment files were checked. Two staff files did not evidence Protection of Vulnerable Adult (POVA) first checks. One staff member is always supervised whilst waiting for CRB check. It is required that POVA 1st checks are carried out prior to start date. Dishwasher tablets were stored under the kitchen sink. This was brought to the manager’s attention. Control of Substances Hazardous to Health (COSHH) requires such items to be locked away. Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 7 It is required that a Lifting Operations, Lifting Equipment Regulation (LOLER) check be carried out on bathroom chair hoists. The manager has since informed CSCI that arrangement has been made for the wheelchairs to be checked and serviced, also the two bath hoists to be LOLER checked. A tour of the home was conducted and found overall free from hazard. Wardrobes throughout the home were not secured therefore posing a potential risk. It is required that that an assessment is carried out to determine risk posed by unsecured wardrobes, and take action to address any identified risks. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home provides a statement of purpose, and service user guide that clearly sets out the objectives and philosophy of the service. Prospective service users are given the opportunity to spend time in the home prior to admission. Each service user is provided with a clear statement of terms and conditions that sets out the terms and conditions of residency. Family and friends are made welcome and visit the home at any reasonable time. The home provides short-stay, respite care and holiday facilities. Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 10 EVIDENCE: Each service user is provided with a written statement of terms and condition of residency. Prospective service users are provided with information to enable them to decide whether Neva Manor is the home where they would like to live. Prior to admission, the home will carry out an initial assessment in order to determine whether the home is able to meet the prospective service user’s needs. There is no specified trial period as such. The duration is agreed between the home and service user. The service user is also provided with a clearly written Statement of Purpose and a Service User’s Guide. The Statement of Purpose has been updated recently. Two service users spoken with confirmed that they had support choosing the home. Four service users care plan sampled evidenced that they have received a contract. These were signed and dated by the service user. One care plan sampled provided evidence of pre-admission initial assessment for a recent admission. The short-term care plan was written on the day of admission. Service users for both long and short term stays are encouraged to achieve and maintain independence. For those in short term stays, the home endeavours to aid their rehabilitation process so that they can cope more readily at home and in the community. Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care plan sampled evidenced good medical and personal care provided by the home. Controlled drugs entries were supported by two staff signatures. The home also maintain accurate receipt of all medication received. Care plans contained details about service users’ social history. Service users were observed to be treated respectfully by staff. Care plans included the wishes of individuals regarding terminal care and arrangements after death. Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 12 EVIDENCE: The inspector sampled four service users care plan. These evidenced good standard of health care provided for the service users. The care plan file included a clear photograph of the service user. The Care Plan provides information such as service user’s social history, dietary preferences, personal hygiene, medical details, mobility, special needs, leisure interests, family and friends. This included details relating to standard eleven. These were up to date. Further details of health care provided were seen in the care plan file. These included GP, Community Nurse, chiropody, and dentist visits. Risk assessments specific to the service user was evidenced in the care plan including falls risks, nutritional screening and manual handling assessments. All service users spoken to confirm that staff treated them with respect and the day-to-day routines in the home respected their dignity. The inspector observed staff interacting with service users in a friendly and professional manner. Staff were seen to be caring and appropriately tactile towards service users. In relation to storage of medication and administration, appropriate levels of medication stock were stored. The lockable medication trolley was kept clean, tidy and organised. Controlled drugs were logged appropriately. No gaps were seen on the Medication Administration Record. Photographs of service users were stored on the medication file. It is recommended that two staff signatures support all hand transcribed entries. Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The routines of the home are planned around the service users’ needs and wishes. Service users are encouraged to personalise their rooms. Appropriate activities are available throughout the home. The service users are satisfied with the meals served at the home. EVIDENCE: The routines of the home were seen to be flexible to meet individuals’ choices and preferences as far as possible. Service users choose to access activities provided by the home or engage in their own hobbies and pastimes. Service users were seen to fulfil their own preferred hobbies such as rug making or knitting. Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 14 Service users are actively encouraged to keep in contact with family and friends living in the community. Visitors are made welcome at any reasonable time. Two service users spoken with confirmed that staff made visitors feel welcome. Service users can choose to entertain visitors in their room, two lounges, or in the dining room. The home provides regular activities. Service users join in the offered activities of their own choosing. Some examples of leisure activities as follows; hairdresser visits, quiz afternoon, bingo, film afternoon, cards, chess or draughts, quiet reading. Extra activities provided are piano performance, lunches out (pub meal or fish & chips on the seafront), aromatherapy, flower arranging, monthly Church service, service user’s birthday parties, carnival night, summer barbecue with family members, and organist performance. Service users have also enjoyed local Girl Guides singing performances. On the day of the inspection, one-to-one activities were seen to be offered such as skittles. One service user went out during the afternoon with the Blind Association for a social meeting. The inspector received positive feedback through discussion with service users. Service users spoke of piano performances and buffet tea for special occasions. The manager conducts service users surveys on a yearly basis. The manager seeks the service user’s satisfaction and opinion on the service for example, meal options. Service users meetings are booked in advance and take place every two months. Service users review meeting are held with the service user, their family and social worker. Lunchtime routine was observed during the inspection. The dining area is well lit and spacious. Tables were decorated with linen tablecloth and tablemats. Choices of cold drinks were offered. The meal was chicken pie, steamed vegetables and potatoes. Gravy was provided in a gravy boat. The pudding was apple crumble and custard followed with a cup of tea or coffee if so wished. The dinner served appeared hot and tasty. Mealtime was seen to be unhurried, and discreet support was available for service users if needed. Staff were seen to offer service user support with mealtime in a caring and sensitive manner. The atmosphere was relaxed. There were good-natured interaction between staff and service users. Service user informed the inspector that fresh fruits are provided throughout the day. It was also noted that cold drinks were provided in service users bedrooms such as orange squash. Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users were confident that they could raise complaints or concerns with senior staff. Three staff recruitment files did not contain evidence of Protection of Vulnerable Adult (POVA) first and Criminal Records Bureau (CRB) checks. The home has policies and procedures in place to ensure the protection of service users living at Neva Manor. EVIDENCE: None of the service users spoken to had any complaints about the home and all were clear that should they have any complaints, they would speak to the manager or another senior member of staff. Service user felt that the manager would deal with any problems. Staff spoken to were clear that they would pass on any complaints to the manager. Staff and service users confirmed that they would not hesitate to approach the manager or a senior member of staff should they have any concern. All service users are registered to vote and their legal rights protected by the homes values, policies and procedures. At present, two service users prefer to Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 16 opt out of electoral voting; one service user visits the polling station and the remaining service users use postal ballot. Out of four staff recruitment files sampled, one had Criminal Records Bureau (CRB) check carried out. The manager has since provided CSCI with a copy of the second staff member’s CRB check (which was stored elsewhere on the day of the inspection). Two other newly recruited staff file did not evidence Protection of Vulnerable Adult (POVA) first checks. One staff member is always supervised whilst waiting for CRB check. It is required that POVA 1st checks are carried out prior to start date. The Complaints procedure, Abuse policy and Whistleblowing policy were seen. The Complaints procedure included the Commission of Social Care Inspection contact details. Neva Manor’s Policy and procedure for Disclosure of Abuse and Bad Practise outlines details for staff regarding roles and responsibilities. The home also has access to Safeguarding Vulnerable Adult in Somerset MultiAgency Policy if needed. The Abuse policy and Whistleblowing policy could be further improved with clearer reporting procedures including contact details for all statutory agencies. There have been no complaints made to the home. Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home provides an overall safe environment. The home has a homely environment, which provides aids and equipment to meet the care needs of the service users. Communal space is good. Service users have some options of where to meet relatives and friends in privacy and comfort. The home was clean and hygienic on the day of inspection. EVIDENCE: The home comprise of a large converted Victorian house. The accommodation is situated over two floors with a chair lift and stairs for accessing the upper floor. Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 18 A lounge and dining area is situated at the rear of the property and there is an additional quiet lounge situated at the front of the home. The dining room is designated for those, who choose to smoke. The dining room is next to the kitchen and is part of an open plan area linking to a large television lounge. This impinges on other people’s health through passive smoking and air quality near the kitchen. It is recommended that the home consider reviewing the current arrangement and smoking policy. The home was clean and tidy on the day of the inspection. A tour of the premises was undertaken and the inspector viewed all the communal areas and some of the service users’ private bedrooms. All service users’ rooms viewed had been personalised to reflect individuals’ choices and preferences. Service users rooms were well personalised with items such as thimble collection, dolls, photographs, pictures and pot plants. Service users were able to keep whatever they wanted in their rooms to suit their lifestyle. Some services users had alcoholic drinks in their room, which they could enjoy in the evening. Three service users spoken with said they liked their rooms. There are twelve single bedrooms and two double bedrooms, ten of which have en-suite facilities and one double bedroom with en-suite facilities. Three single rooms are located on the ground floor and nine single rooms and one double room including a toilet and two bathrooms on the first floor. There is also an assisted bathroom and toilet on the ground floor. Two bathrooms had a chair hoist facility, which will require checking. Call bells are available in bedrooms, toilets and bathrooms. A stair lift is available for service users who find it difficult to use stairs. The kitchen area was inspected and found to be clean and hygienic. Dishwasher tablets were stored under the kitchen sink. This was brought to the manager’s attention. Good laundry facilities are provided and a service user spoken to confirmed their clothes were always well laundered and returned to them promptly in good condition. The home is generally well maintained and has a homely feel. Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home had sufficient staff on duty and staff are qualified to provide good level of care. Service users have confidence in the staff that care for them. All staff are clear regarding their role in what is expected of them. EVIDENCE: On the day of the inspection, there were two care assistants, one deputy and the manager on duty. During the afternoon, there were two care assistants and one deputy. One sleep-in duty and one waking night staff were rostered for night duty. There are currently fourteen care staff, one deputy, one senior and the manager. Four staff files were checked. Three staff files did not contain POVA first check and CRB disclosure. Three staff files evidenced two references. Not all files contained photograph identification. The manager has since provided CSCI with a copy of one staff member’s CRB check (which was stored elsewhere on the day of the inspection). One staff member is always supervised whilst waiting for CRB check. It is required that POVA 1st checks are carried out prior to start date. Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 20 Training provided included administration of medicine, diabetes, vision awareness, manual handling, food hygiene, first aid, and fire training updates. Out of the two staff files sampled, training records showed that two staff member have completed National Vocational Qualification (NVQ) 2. Staff spoken with had an awareness of Complaint procedure and Vulnerable Adults policy. However, it is recommended that all staff receive Protection of Vulnerable Adults (POVA) training to further develop their understanding of correct protocols. Staff spoken with stated they felt supported and confirmed that the manager operated an ‘open door’ policy that is they felt able to approach her with any queries. Service users spoken to were very complimentary about staff and they were described as ‘Wonderful, I am generally happy with the staff – they’re all quite cheery’. The inspector spoke with an NVQ assessor who was visiting the home that day. The NVQ assessor has been visiting the service since October 2006. The assessor commented that the staff are relaxed and helpful. The assessor also stated that the atmosphere in the home is good, friendly and has a homelike feel. Two staff are currently progressing through their NVQ level 2. The manager is planning to book in more staff in the near future in order to increase the level of NVQ trained staff. Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37, 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The manager has the required skills and experience to run the home. Service users and staff are kept informed and involved in the running of the home. Service users are able to take responsibility for their own finances but if they are not able to do so robust systems are in place to safeguard their financial interests. The home has clear health and safety policies and regular checks take place to ensure that the home is a safe environment. Some areas of health and safety will require improvement. Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 22 EVIDENCE: Mr Dharma Bungaroo and Mrs Devianee Bungaroo are the registered providers. The registered care manager is Ms Kimberley Neale and one deputy supports her. Kimberley has worked in the home for five years. She is currently progressing through the Registered Manager’s Award (RMA) and has attained NVQ 2 and 3 in care. Kimberley oversees the overall running of the home, staff team, health and safety and administration. Service users spoken to stated that they felt the manager is approachable and that they felt listened to. Records were kept for the management of personal allowances. This was sampled and checked for three service users. These finance records were supported by two signatures be it two staff or staff and service user. The final balance was correct. Staff spoken with confirmed that they felt supported and able to approach the manager and senior staff should they wish to discuss day-to-day running of the home. One staff said ‘It’s really nice here. I like working here’. Three staff spoken with stated that they have received induction training and formal oneto-one supervision. The fire records seen during the inspection demonstrated that weekly audits were carried out. The last check was completed on 20th February 2007. A tour of the premises was made and the majority of areas seen were free from hazards. Wardrobes throughout the home were not secured therefore posing a potential risk. It is required that that an assessment is carried out to determine risk posed by unsecured wardrobes, and take action to address any identified risks. The home displays a current certificate of Employer’s Liability Insurance. Records were seen that showed the following; fire equipment, water temperature checks, Gas Landlord Register, Portable Appliance Testing (PAT) and stair lift tests were subject to regular checks and had been serviced. The home was in the process of arranging an external agency to test and check the water system as preventative strategy against Legionella. The manager has since sent in a copy of certificate of results, which took place on 7th March 2007 and confirms no bacteria present. It is required that a Lifting Operations, Lifting Equipment Regulation (LOLER) check be carried out on bathroom chair hoists every six months. The manager has since informed CSCI that arrangement has been made for the wheelchairs to be checked and serviced, also the two bath hoists to be LOLER checked. The Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 23 manager has also sent CSCI copies of previous LOLER checks, which took place on 3.3.05 and recent checks made on 14.3.07. The manager maintains accident and incident records. These reflected low accident rates. The manager conducts internal quality assurance audits that are methodical. The audits are carried out annually relating to service users satisfaction. Service user’s meetings are also arranged every two months. Staff supervision take place on a monthly basis and staff spoken with confirmed this. Staff meeting take place every two to three months and management meeting take place with the owners on a monthly basis to ensure regular communication. Fridge/ freezer temperatures were within the correct range on that day. The inspector noted that the home has a cleaning schedule but no record to demonstrate task have been completed. It is recommended that cleaning task are recorded and maintained in a file. Records were kept for cooked meat temperatures and these were found in the correct range. Dishwasher tablets were stored under the kitchen sink. This was brought to the manager’s attention. Control of Substances Hazardous to Health (COSHH) requires such items to be locked away. Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 2 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 1 Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Not applicable 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 OP29 Regulation 19 (1b) 19 (5d) Schedule 2 13 (4a, c) Requirement It is required that POVA first checks are obtained prior to staff start date. Timescale for action 30/03/07 2. OP38 It is required that hazardous 30/03/07 substances are stored securely in accordance with COSHH regulations. It is required that a LOLER check is carried on bath hoists every six months. It is required that an assessment is carried out to determine risk posed by unsecured wardrobes, and take action to address any identified risks. 30/03/07 3. OP38 13 (4a & 5) 23 (c) 13 (4a) 4. OP38 30/04/07 Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations It is recommended that two staff signatures support all hand transcribed entries on the Medication Administration Record. It is recommended that all staff receive POVA training update as good practice. It is recommended that the Vulnerable Adult and Whistleblowing policies are further improved with clearer reporting procedures including contact details for all statutory agencies. It is recommended that the home consider reviewing the current arrangement and smoking policy. See Standard 20.2. It is recommended that completed cleaning task are recorded and maintained in an appropriate file. 2. 3. OP18 OP18 4. 5. OP20 OP26 Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Neva Manor Residential Care Home DS0000068269.V321973.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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