Inspection on 17/05/06 for Neville House

This inspection was carried out on 17th May 2006.

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

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

Other inspections for this house

Neville House 02/07/08

Neville House 30/07/07

Neville House 07/12/05

Neville House 18/08/05

Neville House 09/03/05

Neville House 10/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Neville House Neville Street Chadderton Oldham OL9 6LD Lead Inspector Michelle Haller Unannounced Inspection 17th May 2006 10:00 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 Neville House DS0000005512.V291057.R01.S.doc Version 5.1 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. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Neville House Address Neville Street Chadderton Oldham OL9 6LD 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) 01616275874 Dr Bhima Odedra Mrs Patricia Grice Care Home 17 Category(ies) of Dementia - over 65 years of age (5), Learning registration, with number disability over 65 years of age (1), Old age, not of places falling within any other category (9), Sensory Impairment over 65 years of age (2) Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 9 OP up to 5 DE (E), up to 1 LD (E) and up to 2 SI (E). 7th December 2005 Date of last inspection Brief Description of the Service: Neville House is a privately owned residential care home for older people. Local amenities such as shops, pubs and a GP practice are close by and bus services run to Oldham centre and surrounding areas. The front of the home faces to a side road. The rear of the premises has a small car park and garden area. The property has been extended to provide accommodation in seven single and five shared rooms. Accommodation is available on the ground and first floors and a passenger lift is available for the use of service users. On the ground floor there is a large lounge and a dining room. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of Neville House was conducted over a six-hour period. Four service user files and records and reports concerning the running were examined. Three members of staff were interviewed and general observations made of the routines in the home and the interaction between service users, staff and other visitors to the home. Three service-users, two relatives were also interviewed. The home was clean and welcoming with a friendly atmosphere, positive and caring relationships between staff and service users was evident and this example has fostered positive and caring relationships between service users. Service users and their representatives were keen to communicate their contentment with the care and support provided by the staff in respect of health, psychological and though to a lesser extent, social care. What the service does well: The home ensures that detailed health and psychological needs assessments are completed prior to a accepting a new service user. Health care is made available to services users and health needs are, for the most part, dealt with promptly. The care plans are detailed and provide staff with information required to meet the health and, to some extent, the psychological needs of the service users. The home ensures that aids and adaptations are made full available so that the skills and independents of service users are maintained for as long as possible. Service users choice, dignity and independence are promoted and the home is open to relatives and friends. Food provided to service users is of good quality, wholesome and plentiful. Neville House is clean and comfortable and has an atmosphere that is homely and welcoming. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The manager must ensure that the social history, personal preferences and cultural expectations are recorded prior to or soon after admission. The service must be able to demonstrate that service users or their representatives are routinely involved when the assessment of needs is undertaken. The home must ensure that service users are accurately weighed and monitored to ensure that service users maintain optimum nutritional status. Connected to this the home must also reintroduce recording the food intake for all service users. The manager needs to review the complaints procedure and ensure that all service users or their representatives are made specifically aware of the complaints procedure and adult protection guidelines. The service should consider the development of the service user plan in a variety of formats so that it is more accessible to service users with visual, hearing or cognitive impairment. As previously identified that home needs to take further steps to ensure that the surface temperature of radiators is safe without compromising the comfort of service users. Tighter control must be exercised over the records made concerning the administration medication in the home. A record of the activities undertaken by service user should be made. The manager must ensure that a variety of activities are made available so that service users of all abilities are given the opportunity to participate. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 7 The quality assurance process must be extended to include staff, family and others who are involved in the home. 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. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 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 Neville House DS0000005512.V291057.R01.S.doc Version 5.1 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 the following standard(s): 1 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service provides potential service users with information that may assist them in making a decision about moving into the home. The home ensures that health and psychological assessments are undertaken prior to or soon after admission, making it possible for each party to determine whether or not the home can meet these needs for individual service users. EVIDENCE: The home’s Statement of Purpose was examined and found to set out the aims and objectives of the home, and also contained the service user guide which provided detail of the service available. This document was placed at the entrance of the home and was also seen in a significant number of bedrooms. Four service user files were examined including those of the most recent admission to the home. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 10 Completed assessments of health need were noted on all files, and additional information such as moving and handling risk assessments and, communication assessments were also available. It was noted however, that only two of the four files examined, contained information about the social history and cultural preferences of service users. There was limited evidence that service users had been involved in completion of the assessments compiled by the home, however, when questioned the relative of the most recent admission stated that the family and the service user had been interviewed prior to and following admission The manager must ensure that the social history, personal preferences and cultural expectations are routinely recorded prior to or soon after admission. The service must be able to demonstrate that service users or their representatives are routinely involved when the assessment of needs is undertaken. The service should consider the development of the statement of purpose and service user guide in a variety of formats so that it is more accessible to service users with visual, cognitive or other sensory impairments or learning disabilities. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users health and personal care needs are generally set out in a care plan that ensures, for the most part, appropriate health care is provided and promoted. The practices relating to the administration of medication do not consistently promote continued physical health or comfort. The service users right to privacy, respect and compassion is upheld throughout their time at Neville House thereby promoting a sense of self worth and emotional wellbeing. EVIDENCE: Four service user files and other records and reports concerning the provision of health care to service users were examined. Service users, representatives and care staff were also interviewed in relation to assessing the quality of the health care provided in the home. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 12 Cross referencing confirmed that the frequency of reviewing care plans and revising the actions to be taken by staff had been increased to approximately once each month. Care plans were sufficiently detailed to enable staff to easily identify the actions required by them to support service users in maintaining health and independence. There was no evidence however that service users were involved in the development of their care plans and this needs to be addressed. Correspondence and daily records also confirmed that service users are supported in accessing routine and specialist health intervention and advice such as dentistry, podiatry, influenza injection, eye and hearing test, dietician and the tissue viability nurse. It was also noted that referrals to the Falls Clinic were made and any guidance followed, although it must also be noted a high volume of falls had been experienced by this one individual before additional and effective guidance was obtained. Records indicated that service users were weighed each month, however the home does not have a sit and weigh scale and so the recorded weight of those who cannot stand independently may not be accurate. It was noted that two of the four service users whose files were fully examined appeared to have experienced significant weight loss during their time in the home. Furthermore nutritional records are not maintained in sufficient detail to enable an assessment of the food consumed by service users. Daily reports did indicate, however that staff were aware that ‘poor appetite’ was of concern for one person. The home had not reviewed care plans in response to an ongoing health situation specifically reduced appetite and significant weight loss for two service users. This issue was discussed at length with the manager. Her obligation to provide a detailed and accurate record of food consumed by service users was discussed. In addition, the need for an accurate measurement of weight and the development of, care plans that would identify when to involve the GP or dietician was also stressed. Moving and handling equipment was available, and care plans indicated that pressure reducing items such as special mattresses and cushions had been provided following an assessment of the Tissue Viability Nurse. Service users who could give an opinion stated that staff attended to their health care needs and comments included, “ They are very good at answering bells, I’m diabetic so they come and give me a drink of tea and biscuit during the night to keep my blood sugars up’, And ‘When I had a fall the doctor was sent for straight away, even though I said I was alright.” Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 13 Relatives who were interviewed indicated that they were kept informed of any health changes and were confident that steps were taken to maintain and promote good health. In the course of the inspection observation of the routines and interaction between staff and service users was observed, it was noted that rapport was good and staff were patient, calm and in line with care plan instructions. Service user comments included: “The staff are very attentive- everyone is looked after but the staff work very hard to keep a high standard” and “ Whatever we’ve wanted they’ve done the very best for us- done their utmost to give us comfort or what ever we have needed.” Over the course of the day it was noted that call bells were attended to very quickly and a relative who confirmed that this was also the opinion of the person residing in the home commented this on. “…says ‘It’s a good thing that buzzer!’” The medication policy and medication record sheet and file was examined. The policies and procedures remain confusing and again as one problem is resolved another is discovered. This was discussed with the manager and she was advised to access CSCI guidance on medication administration and storage, additional staff training and closer supervision in this area was also advised. During this inspection it was noted that medication had been signed as given when this was not the case. In addition although photographs of service users were on the medication file they were not also on the dossett boxes. The registered provider must take active steps to ensure that medication in the home is administered safely and in accordance with the prescription, furthermore records of medication administration must be made contemporaneously. The registered person must supervise staff more effectively so that policies and procedures are fully understood and followed. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lifestyle of service users does not fully meet the expectations of all service users, however, improvement in the frequency and standard of activities has improved. Service users supported in the choices they are able to make and good contact with family, friends and community-based organisations are maintained on an individual basis. Although there is general satisfaction amongst service users aspects of food provision could be improved to ensure that a wholesome balanced diet is routinely provided to all service users. EVIDENCE: Discussion with service users and their relatives identified that though more would be appreciated, there had been some improvement in the quality and increase in the frequency of activities provided in the home. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 15 An activities calendar has been created and activities include board games, arts and crafts, and Monopoly and card games. An entertainer also visits the home approximately once a month. Discussion with the manager identified that only a limited number of service users could access the activities provided. One service user observed’ ‘A gentleman comes in once a month, he does quizzes and floor games, he is very patient, everyone gets a gift, but only four can really respond to the quiz.’ Service users also stated that a vocalist also visited the home and more were able to join in with the activity of singing along. Service users intimated that activities did occur but it was ‘When staff have time.’ Activities described included armchair exercises, snakes and ladder, and softball. Another service user stated ‘There is a list and I join in with Dominoes- not many players and I have to teach some to play, I enjoy the quizzes- breaks the monotony up.’ Age Concern continues to support a number of service users in developing ‘Life story’ books, however staff do not record the activities enjoyed by service users in consistently. The registered person must ensure that the variety and frequency of activities meet the needs of all service users living in the home. Service users and visitors confirmed that visitors are made welcome and encouraged to continue a positive relationship with their relative, friends and religious or other organisations. During the tour of the private and communal areas it was noted that bedrooms had been personalised by the service users. The general atmosphere in the home was relaxed and service user confirmed that choice was ensured when ever possible. Comments included: ‘The best thing about living here is that we are comfortable and at night we feel safe and secure. We stay down in the morning and after dinner we go upstairs and enjoy our privacy.” Other independent service users echoed this sentiment. Examination of the fridge, freezer and larder revealed a good selection of fresh and frozen meat and frozen vegetables. It was noted that both hot and cold beverages were offered to service users, a good quantity fresh fruit was also available. The dining room is currently also used as the smoking area for service users. Although there was no residual cigarette smoke noticeable over meal times, this arrangement should be reconsidered. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 16 On the day of inspection the freezer and fridge were clean and frost free, and all foodstuff were labelled with a use by or expiry date. Service users were very positive about the food provided in the home saying that it was of good quality. Service users also acknowledged that requests for particular meals were always agreed and they also confirmed that meals, snacks and drinks provided by the home were plentiful and varied. Service users also stated that they had an opportunity to comment on meals during the residence meetings. Comments included: ‘Lovely dinner and they give me food I can manage.’‘ and “I like the food” In response to a previous inspection in August 2005 the manager had introduced a food intake chart but these have been dispensed with, this needs to be resumed. The home must reintroduce recording the food intake for all service users. Discussion with the cook indicated that she was willing to complete courses that would improve her skills in the area of menu planning and the provision of special meals as necessary. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 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 the following standard(s): 16 and 17 Quality in this outcome area is adequate. The home operates a robust complaints procedure providing service users with adequate means for commenting on the care and services provided, however this needs to be reviewed. The service users are protected from abuse by an adult protection policy that is understood and followed by care staff. EVIDENCE: The contents of the homes complaints policy was examined and indicated that complaints are dealt with efficiently and with fairness. Service users were keen to confirm that they were happy to talk to the manager who was considered approachable. One relative stated, “If I have any problems I always say to (the manager).” The complaints procedure is readily available in the Service user guide and in each file. However it was noted the procedure had not been reviewed and updated for a number of years. The home operates a robust adult protection policy that is in line the policy developed by Oldham Metropolitan Borough Council. Discussion with staff established that they had a good understanding of the actions and omissions that constituted elder abuse and were confident about the actions they would take if abuse occurred or was suspected. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 18 However a Protection of Vulnerable Adult (POVA) investigation demonstrated that had not been followed these guidelines. The importance of following procedures in the safeguarding of vulnerable adults was discussed further with the manager during this inspection. Three members of staff were interviewed and each was very clear about the behaviours and omissions that could be classed as adult abuse. Each stated that if they were unhappy with anything they observed in the home or, unhappy with the manner in which an incident was handled they would record the information, speak to the manager or outside authority such as social services, the relatives or ‘The inspectors’. Each was aware of the Adult Protection policy and guidelines. One member of staff was not particularly familiar with the Whistle blowing policy but was clear in their conviction that action would be taken through contacting social service or the police if there were concerns relating to the safety and treatment of an individual or group of service users. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 19 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, well-maintained and accessible environment in which service users reside. The home is clean and free, for the most part, from unpleasant odours and provides a pleasant and hygienic environment in which to live. EVIDENCE: In the course of this announced inspection a tour of the building was undertaken including communal, laundry and storage areas. The main hallway was clean and tidy. The carpets throughout the home were clean. Domestic staff work to a cleaning rota that ensures all equipment, furniture and areas in the home are regularly cleaned. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 20 The lounge area and dining room provides sufficient space for a variety of activities to take place at anyone time and service users were observed reading, knitting and conversing in both areas. However smoking is allowed in the dining room when meals are not being served. All bedrooms were inspected. Many contained furniture belonging to the service users, and furniture that had been provided was of a good quality and well maintained. All shared bedrooms contained partitioning curtains for privacy. The laundry area was clean and the washing machine met with the current water regulations and infection control requirements. Service users were observed accessing all parts of the home independently and a new mobile hoist and slings have been purchased. Service users asserted, during interview, that they liked their bedrooms and had no complaints about any of the physical aspects of living in the home and relatives commented that the home was clean. In order to reduce the risk of scalding to service users radiators must be covered so that a safe surface temperature can be assured. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 21 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, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home ensures that staff are employed in sufficient numbers to meet the needs of the service users. The recruitment and selection protocol offers protects the service users. The majority of staff receive training to help them carry out their duties. EVIDENCE: On the morning of inspection there were 14 service users and the staff compliment consisted of the manager, two carers, one domestic and one cook. This ratio was reduced from the usual staff numbers, however, the needs of service users appeared to be attended to and as previously highlighted call bells were answered quickly and service users were satisfied with the level of care provided in the home. The roster indicated the senior care assistant and one additional care staff were generally on duty. Sick leave and holiday leave was the reason for the reduced numbers on this day. Four staff files were examined and each contained a completed application form, two references and evidence of Criminal Record Bureau (CRB) checks, and additional proof of identity. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 22 Staff files also contained certificates confirming the training that had undertaken. Courses completed included: Safe handling of medication, moving and handling; basic food hygiene; appointed person in an emergency dementia care and challenging behaviour. Domestic staff have received first–aid, infection control and Control of Substances hazardous to health (CoSHH) training. The cook and manager have attended the Safer Food Better Business course provided by the local Health and Safety department. Three members of staff were interviewed and discussion with each demonstrated that they had a basic understanding of infection control and a good understanding of about adult protection and their role in this process. It was clear that a programme of induction was undertaken as a partially completed induction booklet was present on one set of files. Staff confirmed that, they had received supervision and appraisal, and records on file confirmed this. Supervision records demonstrated that the process includes a performance review; team objective; individual objective; training and development need; strength and weakness and additional information such as reports from college. The manager stated that adult protection training; additional courses about Dementia Care and First Aid would be included on the training calendar. The service would benefit from the development of a rolling programme of training made available through colleges, the local authority training unit and independent training organisations. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 23 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager of Neville House ensures to a large extent that the home is run efficiently, safely and for the benefit of service users. The homes quality assurance protocol needs further development to provide all those involved opportunity to comment on the services and facilities available at Neville House. Service users finances are handled appropriately. The health and safety policies, procedures, guidelines and practices protect and promote, for the most part, the welfare of those accessing the home. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 24 EVIDENCE: The manager of Neville House is experienced and has managed the home for in excess of 2 years. During that time she has completed a number of short course and attained the National Vocational Qualification (NVQ) level 4 management award. Discussion indicated that that she is keen to continue learning about the care of older people and managing a care home. Although clearly experienced, there are aspects of care in the home that the manager needs to monitor and supervise more stringently, these areas include medication administration and record keeping concerning diet and activities and the quality of interaction between staff and service users. A quality monitoring system has been introduced and a copy of the Quality Assurance report demonstrated that service users have been involved the quality review of the service. According to the resultant report 70 of service users had an overall impression that the home was ‘Good’ and 25 felt that the home overall was ‘excellent’. This quality assurance protocol needs further development to include all stakeholders so that everyone concerned can have the opportunity to comment on and influence the running of the home. The home also needs to demonstrate how the outcomes from the quality assurance influence the provision of services and the running of the home. The registered provider also visits the home on a monthly basis, assessing the satisfaction of service users and staff. A report of this visit is routinely forwarded to the Commission. Discussion with staff and supervision records confirmed that the manager discusses issues concerning practice and completion of tasks, as a means of maintaining and further raising the standard of work carried out in the home. Observations during the inspection verified that service users and staff are safeguarded in relation to moving and handling practice and updating courses need to be added to the training calendar. The money held for four service users were checked and receipts for all transactions retained. First-aid, infection control and CoSHH training is provided and health and safety signs and posters were strategically placed throughout the home. It was observed that personal protection equipment such as gloves and aprons was Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 25 used and was discussion with staff verified that they had a good understanding of the protocols and actions that prevented that spread of infection. As previously identified that home needs to take further steps to ensure that the surface temperature of radiators is safe without compromising the comfort of service users. Records confirmed that fire safety drills and checks continue to take place regularly and staff were able to describe the homes evacuation policy in the event of a fire. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 26 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 2 x 2 Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Requirement The registered person is required to ensure the records of medicines into the home are fully documented and accountable in accordance with the guidelines of the Royal Pharmaceutical Society of Great Britain. (Previous timescale of 18/08/05 and 01/03/06 not met) Timescale for action 01/08/06 2. OP3 12 (3) 14 (1)(c) The registered person must 01/09/06 ensure that service users or their representatives are involved when the assessment of needs is undertaken or reviewed. The registered person must ensure that a record of food consumed by each service user is available for examination when requested by health or social services. The registered person must demonstrate that service users or their representatives are involved when care plans are reviewed. 01/08/06 3. OP8 17 schedule 4(13) 4. OP7 15 01/09/06 Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 28 5. OP12 16 (2) (m) 16 (2)(m) 6. OP3 7. OP26 23(p) 8. OP33 24 The registered person must provide a variety of activities that will provide a choice of activities for all service users. The registered person must ensure that the social history, personal preferences and cultural expectations are routinely recorded prior to or soon after admission. The registered person must ensure that service users who may fall are safeguarded against equipment, such as radiators, with a high surface temperature. The registered person must extend the quality assurance and monitoring system to include the care staff, family and others involved in the home. 01/09/06 01/09/06 01/08/06 01/09/06 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 Refer to Standard OP1 Good Practice Recommendations The service should consider the development of the statement of purpose and service user guide in a variety of formats so that it is more accessible to service users with visual, cognitive or other sensory impairments or learning disabilities. Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Neville House DS0000005512.V291057.R01.S.doc Version 5.1 Page 30 - 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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