Inspection on 16/01/08 for Neville House Residential Care Home

This inspection was carried out on 16th January 2008.

CSCI found this care home to be providing an Adequate service.

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 Residential Care... 12/01/09

Neville House Residential Care... 08/08/07

Neville House Residential Care... 08/03/07

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

CARE HOMES FOR OLDER PEOPLE Neville House Residential Care Home 12 Montreal Avenue Chapel Allerton Leeds West Yorkshire LS7 4LF Lead Inspector Hebrew Rawlins Key Unannounced Inspection 08:55 16 and 21st January 2008 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 Neville House Residential Care Home DS0000067959.V358166.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. Neville House Residential Care Home DS0000067959.V358166.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Neville House Residential Care Home Address 12 Montreal Avenue Chapel Allerton Leeds West Yorkshire LS7 4LF 0113 2629764 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) SK Care Homes Ltd Mrs Melanie Thompson Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Neville House Residential Care Home DS0000067959.V358166.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2007 Brief Description of the Service: Neville House is a small care home for older people, owned by SK Care Homes Ltd. The home is ideally situated in Chapel Allerton, North Leeds and provides ample car parking and is near local shops. The Post Office, Doctors surgery and Dental surgeries are all within a very short walk. Churches of most denominations are also close by. There is a choice of single and twin-bedded rooms, which are all pleasantly decorated and carpeted. People who live at the home may bring items of their own furniture if they wish. All meals are prepared and cooked on the premises. A flexible menu is planned and served each day and the cook is able to cater for any individual specialised meals or dietary requirements. Neville House aims to provide a family atmosphere where people can join in with the activities and events as much or as little as they wish. The current fees range from £442.00 to 520.00 per week with additional charges for hairdressing, chiropody, newspapers and toiletries. This information was provided to the Commission for Social Care Inspection in January 2008. Neville House Residential Care Home DS0000067959.V358166.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. Information about the inspection process can be found on our website www.csci.org.uk This visit was unannounced and carried out by one inspector who was at the home from 8.55 until 16.00 on 16th January 2008 and from 10.45 until 12.15 on 21st January 2008. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who use the service and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the inspection visit. During the visit a number of documents were looked at and areas of the home used by the people living there were visited. A good proportion of time was spent talking with the people who live at the home as well as with the Deputy manager and staff. The manager had completed an Annual Quality Assurance Assessment (AQAA) before the visit to provide additional information about the home. Survey forms were sent out to the people who use the service, relatives, carers, general practitioners (GPs) and other healthcare professionals. Several were returned and information provided in this way will be reflected in the report. Feedback at the end of this inspection was given to the manager. Thanks are extended to everyone who contributed to the inspection and for the hospitality during the visit. Neville House Residential Care Home DS0000067959.V358166.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? There were eight requirements and two recommendations made in the last inspection report. Four of the eight have been resolved. The manager is making progress with the others and the recommendations have been addressed. The care plans are improving. Pre-admission assessment now forms the basis of a care plan. This helps to make sure the people in the home needs are met. Radiators are fitted with guards or replaced with low surface temperature radiators. This helps to ensure people living in the home are safe. The home has achieved the target figure of 50 of care staff with NVQ level 2 qualifications. This ensures staff are trained to meet the needs of people in the home. The manager has ensured all staff receives supervision and social and leisure activities have improved. Neville House Residential Care Home DS0000067959.V358166.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Neville House Residential Care Home DS0000067959.V358166.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 Neville House Residential Care Home DS0000067959.V358166.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): 1,2,3,5. Standard 6 does not apply to this home. People who use the service experience good quality outcomes in this area. Peoples’ needs are properly assessed before admission, making sure their needs can be met. Contract arrangements are clear and people have enough information about the service to make an informed choice about its ability to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People spoken with said they were given the opportunity to visit and assess the facilities and suitability of Neville House. In people case files looked at there was evidence of comprehensive preadmission assessments. This provides details of peoples condition, health and other professional’s involvement with the individual. Neville House Residential Care Home DS0000067959.V358166.R01.S.doc Version 5.2 Page 10 The home has also introduced a life history form as part of the assessment process. This provides useful information about people’s lives, family, occupation, their preferred way of living including daily routines, hobbies and interests, personal care preferences, spiritual needs and food preferences. From all of the information collected, if the home believes it can meet the person’s needs, a plan of the care needed is written. Neville House Residential Care Home DS0000067959.V358166.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 and 11. People who use the service experience adequate quality outcomes in this area. Peoples care needs are met in a way that respects their privacy and dignity. People’s health care needs are met, although more work is required with care plans and the maintaining of medication records. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Peoples’ health care needs are met, and the new paper work for care planning has the potential to provide good care records if used properly. However, new care plans are not in place as yet for all people, so there is the opportunity for some needs to be overlooked. There was evidence in records that people have access to GPs (General Practitioner), chiropodody, dental and optical services. The medication system was examined. Storage facilities are secure, however the accompanying record Neville House Residential Care Home DS0000067959.V358166.R01.S.doc Version 5.2 Page 12 sheets are not always accurately completed which could put people at risk of been given medication more than once. There was evidence of people’s wishes in respect of end of life care and these are recorded. From discussions with people living at the home and from the returned completed survey forms it is clear that they feel that their dignity and privacy are respected. People living in the home looked well cared for. Staff were good at picking up non verbal cues and made sure that all of the people got attention, support and assistance when they needed it. During conversations with a visitor she said “there are no concerns about this home everyone does their best and the people living here are happy”. Another relative said that carers go out of their way to make sure health care needs are met. Neville House Residential Care Home DS0000067959.V358166.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 and 15. People who use the service experience good quality outcomes in this area. The home has a relaxed and informal atmosphere that promotes flexibility and visitors are made to feel welcome. People are encouraged to take part in social and leisure activities and a good and varied diet is provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Menus are varied and nutritionally balanced. These are developed after consultation with people in the home at meetings or on an individual basis. Meals are served in the dining rooms or people may have their meals in their own room. The dining rooms tables are arranged in small group settings that encourages conversation and makes meal times a social occasion. All people spoken to said they enjoyed the food, one person said “its lovely here”. The lunchtime meal seen on the day was attractively presented. Neville House Residential Care Home DS0000067959.V358166.R01.S.doc Version 5.2 Page 14 The mealtime was relaxed and anyone who needed assistance at meal times was given this discreetly and with courtesy. People living in the home who are able to look after their own money are encouraged to do so. There is an activities programme that includes a visiting ‘motivation’ person twice a week who does exercise, stimulation, quizzes and reminiscence. In the conversations people clearly expressed that they follow their preferred ways of living – getting up times, going to bed, whether to spend time alone or with others, what activities to join in and what to wear. All the people living in the home were well dressed and looked well cared for. Relatives said they are always made welcome and informed of anything that affects their relative. Neville House Residential Care Home DS0000067959.V358166.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 and 18. People who use the service experience good quality outcomes in this area. People and their representatives can be confident that their concerns will be listened to and dealt with. The home has the necessary systems in place to make sure that people are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home records all complaints they receive. No complaints have been made either to the home or the Commission For Social Care Inspection since the last inspection in August 2007. The home has a comprehensive policy and procedure on the action staff should take if abuse is suspected or reported. In discussion with staff they all appeared confident in the action to be taken. Relatives spoken with said information on how to make a complaint was made available to them and people spoken with said they know how to complain. Policies are in place aimed to set out how the home protects service users and prevents harm or abuse and this includes a whistle blowing policy. The manager was aware of the need to report any suspected or alleged abuse to the local authority and other relevant authorities Neville House Residential Care Home DS0000067959.V358166.R01.S.doc Version 5.2 Page 16 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): 19,23,24,25 and 26. People who use the service experience good quality outcomes in this area. People live in a homely environment that is clean, comfortable, and generally well maintained making it a nice place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is welcoming and provides a homely atmosphere. All bedrooms seen were tastefully decorated. All the people living in the home and relatives spoken with said the home was always clean and free from offensive odours. Gloves, aprons and alcohol gel is provided and used by all staff. Infection control procedures and policy are in place. No obvious health and safety hazards were noted. Neville House Residential Care Home DS0000067959.V358166.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. People who use the service experience good quality outcomes in this area. There appear to be enough staff to meet the needs of people in the home. They are protected by the homes recruitment procedures. Overall staff are well trained for their roles. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The comments made by people living in the home were very positive about the staff and they complimented their care and kindness in meeting their personal needs. The personnel records for two staff were seen to make sure that the appropriate checks had been made and the other documentation that must be sought before someone starts work was completed. There was evidence this was done. The deputy manager confirmed that CRB/POVA (Criminal Record Bureau/Protection of Vulnerable Adult) checks were undertaken before each person-started work. This ensures these people employed are safe to work with the people living in the home. Neville House Residential Care Home DS0000067959.V358166.R01.S.doc Version 5.2 Page 18 There was evidence of ongoing training (fire procedures, first aid and moving and handling) to keep staff up to date with safe working practices. There is also an ongoing programme of NVQ (National Vocational Qualification) training; over 60 of care staff have achieved an NVQ. Staff said they felt supported by the manager and they receive regular supervision. Neville House Residential Care Home DS0000067959.V358166.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33, 35,36,37 and 38. People who use the service experience good quality outcomes in this area. The manager provides effective leadership. The health and safety of people is promoted and protected. This makes it a safe and good place to live in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has achieved the Registered Manager’s Award and has many years experience in care management. She has clear ideas about how care should be delivered and high expectations of the staff team. Staff meetings are being held, individual supervision sessions are up and running and meetings are held on a regular basis with people living in the Neville House Residential Care Home DS0000067959.V358166.R01.S.doc Version 5.2 Page 20 home. One member of staff said that the manager’s style was to encourage ideas and felt that this was good for morale. Servicing of equipment takes place as required and a selection of service certificates were seen, along with the records of fire alarm tests which show a different actuation point is tested each time. Training records show that all staff have received training in health and safety. Staff were observed using correct methods of moving and handling. Financial records were seen, where people cannot look after their finances themselves, good records were in place. The manager is working on developing quality-monitoring audit of services that include the opinions of people living in the home, relatives, staff and external professionals that visit the home. Neville House Residential Care Home DS0000067959.V358166.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 x 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 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 x 18 3 3 x x x 3 3 3 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 3 3 x 3 3 x 3 Neville House Residential Care Home DS0000067959.V358166.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15(1) Requirement People living at the home must have an up to date, detailed care plan and this must be reviewed regularly. This will ensure they receive the support that meets their needs When medication is administered to people living at the home it must be clearly recorded. This will ensure people receive the correct levels of medication. Previous timescales of 24/09/07 not met. Timescale for action 01/04/08 2. OP9 13(2) 01/04/08 3. OP33 24 The home must undertake a 01/06/08 quality-monitoring audit of services that include the opinions of residents, relatives, staff and external professionals that visit the home. This would enable them to judge the quality of service they provide. Previous timescales of 24/09/07 not met. Neville House Residential Care Home DS0000067959.V358166.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Neville House Residential Care Home DS0000067959.V358166.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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. 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