Inspection on 07/12/05 for Neville House

This inspection was carried out on 7th December 2005.

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

The inspector 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 17/05/06

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 Announced Inspection 7th December 2005 09:00 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.V263149.R01.S.doc Version 5.0 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.V263149.R01.S.doc Version 5.0 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.V263149.R01.S.doc Version 5.0 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). 18th August 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.V263149.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of Neville House was announced and conducted over a six-hour period. Three service user files and record and reports concerning the running were examined. Two 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. Six service-user, two relatives and one general practitioner comment cards were returned to the Commission for Social care Inspection (CSCI)- The comments made about the home were very complimentary and positive. The home is warm with a friendly atmosphere, positive and caring relationships between staff and service users was evident and the ethos of the home 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 social care. What the service does well: What has improved since the last inspection? Neville House DS0000005512.V263149.R01.S.doc Version 5.0 Page 6 Development and review of care plans has improved and now relate more closely to the assessed and changing needs of service users. A cleaning programme that covers all areas in the home has been introduced. The practice and actions taken by staff are more closely monitored. Records of the food intake of service users have been introduced for very frail service users. What they could do better: 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.V263149.R01.S.doc Version 5.0 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 Neville House DS0000005512.V263149.R01.S.doc Version 5.0 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 Service users are only accepted by the home following a comprehensive assessment of needs. EVIDENCE: Three service user care files were examined and each held a copy of an assessment of health, psychological and social needs carried out by the socialworker or manager of Neville House. All other standard concerning the home’s ability to meet the needs of prospective service users was assessed in the previous inspection in July 2005 and were considered to be satisfactory. Neville House DS0000005512.V263149.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Service users care plans, for the most part, reflect the assessed needs of the service users. The health needs of service users are met. The service users right to privacy, respect and compassion is upheld throughout their time at Neville House. The home’s medication policy needs to be revised. EVIDENCE: Three service user files and other records and reports concerning the provision of health care to service users were examined. The information provided in the returned comment cards has also been used to assess the standard of health care provided in the home. Examination of records confirmed that the frequency of reviewing care plans and revising the actions to be taken by staff had been increased to approximately once in six weeks. Neville House DS0000005512.V263149.R01.S.doc Version 5.0 Page 10 It was noted that care plans are now more detailed, enabling staff to easily identify the actions required by them to support service users in maintaining health and independence. 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. Service users assessed as being at risk of developing pressure sores described the actions taken by staff, including the use of lifting equipment and provision of pressure reduction mattresses and cushions. 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 here respectful at all times. Service users confirmed that staff were very attentive and one person commented: ‘You only have to press the button and they’re there.’ The general practitioner was very positive about their experience of Neville House identifying that communication between the home and health professionals is good, that staff follow instructions, that service users privacy is respected, and remarking, ‘I have every confidence in the staff’. The medication policy and procedures used in the home were examined and observation made of staff administering medication. The policies and procedures are muddled; with the result that, as one problem is resolved another is discovered. This was discussed with the manager and a referral to the CSCI pharmacy inspector for advice was agreed. Neville House DS0000005512.V263149.R01.S.doc Version 5.0 Page 11 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 The social needs of service users could be better met. Service users are encouraged to maintain contact with family and friends. Service users are able to keep control of their lives. Meals provided in the home are varied and wholesome. EVIDENCE: Discussion with service users and their relatives identified that some feel that there are insufficient activities provided both in and out of the home, however of the six comment cards returned only one was unhappy with the level of activities. Daily reports did not detail the activities in which service users participated. The manager acknowledge that a daily activities plan should be developed and displayed so that service users are given the opportunity to participate in a variety of activities within the home. It was noted that Age Concern continues to support a number of service users in developing ‘Life story’ books. Service users confirmed that visitors continue to be made welcome and encouraged to continue a positive relationship with their relative or friend. Neville House DS0000005512.V263149.R01.S.doc Version 5.0 Page 12 During the tour of the private and communal areas it was noted that bedrooms had been personalised by the service users. 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. On the day of inspection the freezer and fridge were clean and defrosted, 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. Comments included: ‘I am diabetic and the meals are very suitable’ and ‘The food is great, especially dinner’. In response to the home’s previous inspection in August 2005 the manager has introduced a food intake chart to be completed for the most frail service users. The need to introduce a method of recording the food intake of all service users was discussed, however the commission accepts that the home has made a significant improvement in this area. Neville House DS0000005512.V263149.R01.S.doc Version 5.0 Page 13 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, 17 and 18 The home operates a robust complaints procedure. The service users are protected from abuse. EVIDENCE: The contents of the home’s complaints policy confirmed that complaints are dealt with efficiently and with fairness. Service users and relatives stated that they were aware of the complaints procedure, but had never felt the need to use the policy. Service users asserted that if they had any complaints or concerns they were confident that it would be dealt with by the manager. Correspondence verified that service users are placed on the electoral register when they move into Neville House. The manager confirmed that most service users voted by post. The home operates a robust adult abuse 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. Staff also receive training about adult protection. Neville House DS0000005512.V263149.R01.S.doc Version 5.0 Page 14 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 The home is well maintained. The home is clean and free from unpleasant odours. 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 have devised a cleaning plan to ensure that all equipment, furniture and areas in the home are regularly cleaned. 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. Neville House DS0000005512.V263149.R01.S.doc Version 5.0 Page 15 All bedrooms were inspected. Many contained furniture belonging to the service users. Shared bedrooms contained partitioning curtains for use as necessary. All the bedroom radiators had been fitted with guards. The laundry area was clean and the equipment met with the current water regulations and infection control requirements. Service users asserted, during interview and through the comment cards, that they liked their bedrooms and had no complaints about any of the physical aspects of living in the home Neville House DS0000005512.V263149.R01.S.doc Version 5.0 Page 16 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 and 30 The home ensures that staff are employed in sufficient numbers with the appropriate experience and skills to meet the needs of the service users. The recruitment and selection protocol protects the service users. Staff are trained to carry out their duties. EVIDENCE: On the morning of inspection there were 16 service users living at Neville House and staff on duty included the manager and senior care assistant, three care staff, one domestic and one cook. Examination of the staff roster confirmed that this general staff compliment for weekday mornings. The homes recruitment and selection process includes seeking two references and applying for POVA and CRB checks. Two staff files were examined and each contained a copy of a completed application form, documents concerning proof of identity and confirmation of address and verification for completed CRB checks. Staff files also contained certificates confirming the training that had undertaken. Courses completed in 2005 included: Infection control; Risk assessment, basic food hygiene, moving and handling and fire training, eye care awareness, dementia and challenging behaviour. The manager had stated in the pre-inspection report that five of the ten care staff employed in the home had attained NVQ in Care level 2 award. Neville House DS0000005512.V263149.R01.S.doc Version 5.0 Page 17 The manager indicated that the training calendar for 2006 would include specialist courses such as dementia care. Domestic staff have received first–aid, infection control and Control of Substances hazardous to health (COSHH) training. Neville House DS0000005512.V263149.R01.S.doc Version 5.0 Page 18 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, 36 and 38 A competent and qualified individual manages Neville House. The home’s quality assurance protocol needs further development. Service users finances appear to be handled appropriately. The health, safety and welfare of those accessing the home are safeguarded. EVIDENCE: The manager of Neville House is experienced in managing a care home and has recently attained the National Vocational Qualification level 4 management award. It was noted that the manager felt that completing the course had increased her knowledge and improved her management skills. Further discussion identified the managers’ eagerness to continue attending courses. Neville House DS0000005512.V263149.R01.S.doc Version 5.0 Page 19 The home’s quality assurance protocol needs further development to ensure all stakeholders have the opportunity to comment on and influence the running of the home. Discussion and the scrutiny records indicated that management take into account the views of those who receive and provide a service. 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. The money held for three service users were checked and receipts for all transactions were retained. First-aid, infection control and COHSH training is provided and health and safety signs and posters were strategically placed throughout the home. 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.V263149.R01.S.doc Version 5.0 Page 20 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 N/A 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 3 x 3 Neville House DS0000005512.V263149.R01.S.doc Version 5.0 Page 21 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 Timescale for action 01/03/06 2 OP12 16 (2) (m) 3 OP33 24 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 not met) The registered person must 01/03/06 following consultation with service users provide a program of activities. (Previous timescale of 01/10/05 not met) The registered person must 01/03/06 introduce a quality assurance and monitoring system. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Neville House DS0000005512.V263149.R01.S.doc Version 5.0 Page 22 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.V263149.R01.S.doc Version 5.0 Page 23 - 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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