Inspection on 08/08/07 for Neville House Residential Care Home

This inspection was carried out on 8th August 2007.

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 Residential Care... 12/01/09

Neville House Residential Care... 16/01/08

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 8th August 2007 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 Residential Care Home DS0000067959.V344649.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.V344649.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 *** Vacant *** 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.V344649.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th March 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 in the activities and events as much or 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. Neville House Residential Care Home DS0000067959.V344649.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 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 09.00 until 16.30 on 8th August 2007. 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 and all 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 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 before the visit 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. What the service does well: Neville House Residential Care Home DS0000067959.V344649.R01.S.doc Version 5.2 Page 6 People are happy in the home and comments were without exception complementary showing that individuals lead a lifestyle that suits them. All individuals spoken to felt that they are treated with respect and their needs are understood by staff. The manager has done well in getting staff and people who use the service on board. The staff feel that a number of improvements have made staff morale good. What has improved since the last inspection? What they could do better: Pre-admission assessment must provide sufficient information about the person’s needs and strengths in all aspects of their care, to form the basis of a care plan. Every person must have a signed contract showing the terms and conditions of residency so people know what they are entitled to. Medication administration sheets must always be completed for each person. The records should show when people refuse their medication and why. If this persists the GP should be informed otherwise peoples’ health could be at risk. Care plans did not have clear and precise instructions for staff about how to deliver care according to needs. This means that there is a risk people’s needs may be overlooked. The home should review its daily activities. One relative said, “I feel people are not offered enough stimulation on a day to day basis and those who don’t want to do anything should be encouraged”. Neville House Residential Care Home DS0000067959.V344649.R01.S.doc Version 5.2 Page 7 The documentations, policies, records and practices are all must be reviewed, which will lead to improvements being implemented. A comprehensive training programme must be established for all staff members, to make sure they are equipped to do their job. Regular staff supervision must be introduced and maintained and regular meetings involving management, staff, people living in the home and relatives must take place so that people are well informed. 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.V344649.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.V344649.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, and 5. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are able to visit the home and have access to some written information so that they can make an informed choice about moving in. However an up to date brochure of the facilities is needed. The home’s pre-admission assessment information does not provide enough detailed information about the precise needs of people, in all aspects of their care, which means that on admission some needs may be overlooked. EVIDENCE: Three care plans were looked at. There were assessment details in the three records sampled, but the home’s pre-admission assessment did not provide sufficient information about the person’s needs and strengths in all aspects of Neville House Residential Care Home DS0000067959.V344649.R01.S.doc Version 5.2 Page 10 their care, and there was not enough information to form the basis of a care plan. The manager said an up to date brochure of the facilities is to be introduced and made available to prospective people thinking of coming to the home, their relatives and social workers. People spoken with said they and their relatives had the opportunity to visit and assess the facilities and suitability of Neville House. Neville House Residential Care Home DS0000067959.V344649.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. This judgement has been made using available evidence including a visit to this service. Staff are aware of the specific needs of the people in the home but because these are not recorded, there is always the possibility that some care may not always be delivered according to the person’s needs and wishes. People’s health care needs are met, however medication practices are not always delivered according to the home’s policy placing people at potential risk. EVIDENCE: Medication administration sheets were not always completed for each person. The records should show when people refuse their medication and why. If this persists the GP should be informed otherwise peoples’ health could be at risk. Neville House Residential Care Home DS0000067959.V344649.R01.S.doc Version 5.2 Page 12 Care plans did not have clear and precise instructions for staff about how to deliver care according to needs. There were no care plans giving instructions for staff on how to manage people that have short-term memory. Falls risk assessments and nutritional assessments were not always fully completed. People’s care plans reviews have not always taken place and there was no evidence to show that people using the service or their relatives are involved in the care plans. The new manager was aware of the shortfalls in care plans, and said that the company is introducing a new style format. These should be introduced in the home by the end of October 2007. There was evidence in records that people have access to GPs (General Practitioner), chiropody, dental and optical services. Throughout the inspection staff respected the privacy of people living at the home and always knocked before entering bedrooms. 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 Neville House Residential Care Home DS0000067959.V344649.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 and 15. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are able to spend their day how they choose and the home tries to provide as many activities as possible. Visitors are made to feel welcome and a good and varied diet is provided. EVIDENCE: Visitors spoken with on the day of the visit said that they were always made welcome and the staff looked after their relative very well. The home organises movement sessions, quizzes, art and craft and various other activities including trips out, but comments from some people spoken to and survey forms indicated that these did not meet their needs. Comments included, “I don’t always like the activities” “I like things that stretches the mind” “I would like to be taken out to do shopping”. One relative said “I feel people are not offered enough stimulation on a day to day basis and those who don’t want to do anything should be encouraged”. Neville House Residential Care Home DS0000067959.V344649.R01.S.doc Version 5.2 Page 14 The cook has been at the home for number of years and understands the needs of the people who live in the home very well. Relative said “the food is well prepared and presented”. All people spoken to living in the home said the food at the home was very good. On the day of the inspection several people visited the home, and they all appeared to have a good rapport with staff. Neville House Residential Care Home DS0000067959.V344649.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. This judgement has been made using available evidence including a visit to this service. The staff team are aware of what to do if abuse is suspected or reported. People in the home are confident that complaints will be taken seriously. EVIDENCE: Returned people’ survey forms showed that people in the home know how to make a complaint. Relatives spoken with are clear about whom to talk to if they have an issue of concern. Two people who use the service said “the manager is good at listening and always try to put things right”. Since the last inspection the home has employed a new manager whom people in the home have confidence in. No complaints have been made to the Commission for Social Care Inspection. The manager of the home is aware of her responsibility to report any serious complaints to the Commission for Social Care Inspection. Neville House Residential Care Home DS0000067959.V344649.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): 19,20,23,24, 25 and 26. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is clean and tidy throughout and offers a safe environment in which the people are able to live in comfort. EVIDENCE: The home is very well maintained, although radiator covers are needed to protect people from burns. The manager said there is a planned programme in place to guard all the radiators over the coming year. The manager also said the fire safety system will be upgraded. Quotes are being collated and work will be completed by October 31st 2007. Neville House Residential Care Home DS0000067959.V344649.R01.S.doc Version 5.2 Page 17 Communal areas are furnished and decorated to a good standard providing light and spacious accommodation. Bedrooms seen were decorated and furnished to a good standard. People living in the home said that they were pleased with their rooms and were glad to have many of their own personal belongings with them. All areas of the home were clean, tidy and free of unpleasant odours. In returned survey cards from people living in the home, all said the home was clean and free from offensive odours. The laundry facilities are well equipped to meet the needs of the people in the home. The kitchen was clean and tidy throughout and the cook said all equipment was in working order. Neville House Residential Care Home DS0000067959.V344649.R01.S.doc Version 5.2 Page 18 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. This judgement has been made using available evidence including a visit to this service. Competent staff meet the needs of the people in the home and they are protected by the recruitment procedures. EVIDENCE: The recruitment files of two members of staff, appointed since the last inspection, were sampled and found to contain all the necessary checks to make sure that the person was safe and suitable to work with vulnerable people. The manager said the company is reviewing staff contracts and new contracts will be issued within weeks. In discussion with staff, it was clear that morale amongst staff has improved since the arrival of new manager. Observation during the day showed that there were sufficient numbers of staff on duty to care for the people in a calm and relaxed way. Staff had time to talk to individuals and provide assistance at the time needed. Staff were seen to have good attitudes and they clearly put the needs and wishes of the people in the home first. People spoken to said that staff are supportive. All comments made were positive and complementary showing Neville House Residential Care Home DS0000067959.V344649.R01.S.doc Version 5.2 Page 19 high levels of satisfaction amongst people using the service. Domestics ensured the home is clean and tidy. The cultural and racial mix amongst the staff team matches that of people using the service and the wider community. There is a clear commitment from the manager to making sure that the staff are trained and competent. She is in the process of gathering information as to what training staff have had over the years. Several staff have completed the National Vocational Qualification (NVQ) in care at level 2 or above. Staff spoken with are enthusiastic about training. Neville House Residential Care Home DS0000067959.V344649.R01.S.doc Version 5.2 Page 20 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, 33, 36, 37 and 38. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The interests of people living in the home are very important to the manager, she is working hard to make this a good home. EVIDENCE: The new manager is well thought of by the staff team and people living in the home. Staff felt well supported during what was felt to be a difficult period in ownership and management. Staff said that since the new manager has arrived she has supported them well, morale has increased and they have positive support and information. Neville House Residential Care Home DS0000067959.V344649.R01.S.doc Version 5.2 Page 21 The home’s risk management system ensures that equipment and appliances are regularly serviced and maintained. A new Fire Safety System is to be installed with appropriate training and documentation put into place. The manager said documentations, policies, records and practices are all under reviews, which will lead to improvements being implemented. She will also ensure a comprehensive training programme is established for all staff members. Regular staff supervision is to be introduced and maintained and regular meetings is planned involving management, staff, people living in the home and relatives. Neville House Residential Care Home DS0000067959.V344649.R01.S.doc Version 5.2 Page 22 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 2 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 3 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 3 3 Neville House Residential Care Home DS0000067959.V344649.R01.S.doc Version 5.2 Page 23 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 OP3 Regulation 14 Requirement Pre-admission assessment must provide sufficient information about the person’s needs and strengths in all aspects of their care, to form the basis of a care plan. 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 (raised last inspection) 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. (raised last inspection) Staff must have adult protection training to ensure that people living at the home are not at risk. (raised last inspection) Radiators must be fitted with guards or replaced with low surface temperature radiators. Timescale for action 24/09/07 2. OP7 15(1) 24/09/07 3. OP9 13(2) 24/09/07 4. OP18 13(5) 24/09/07 5. OP25 13(4) 24/11/07 Neville House Residential Care Home DS0000067959.V344649.R01.S.doc Version 5.2 Page 24 6. OP28 18 7. OP36 18 The home must achieve the target figure of 50 of care staff with NVQ level 2 qualifications. (raised last inspection) A comprehensive training programme must be established for all staff members, to make sure they are equipped to do their job. 24/09/07 24/09/07 8. OP33 24 The home must undertake a 24/09/07 quality-monitoring audit of services that include the opinions of residents, relatives, staff and external professionals that visit the home. (raised last inspection) 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. 2. Refer to Standard OP36 OP12 Good Practice Recommendations When the manager arrives he/she should ensure all staff receive supervision at least six times a year. The home needs to improve its social and leisure activities. This will help to ensure residents are not bored. Neville House Residential Care Home DS0000067959.V344649.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Neville House Residential Care Home DS0000067959.V344649.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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