Inspection on 02/02/06 for New Line Residential Home

This inspection was carried out on 2nd February 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

New Line Residential Home 16/07/07

New Line Residential Home 15/08/06

New Line Residential Home 21/07/05

New Line Residential Home 05/10/04

New Line Residential Home 20/04/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE New Line Residential Home 28 New Line Greengates Bradford West Yorkshire BD10 9AS Lead Inspector Steve Marsh Unannounced Inspection 2nd February 2006 09:30 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 New Line Residential Home DS0000001283.V276839.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. New Line Residential Home DS0000001283.V276839.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service New Line Residential Home Address 28 New Line Greengates Bradford West Yorkshire BD10 9AS 01274 616631 01274 617007 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) Mrs Angela Copley Mrs Tracey Yeadon Care Home 16 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (11), of places Physical disability over 65 years of age (1) New Line Residential Home DS0000001283.V276839.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st July 2005 Brief Description of the Service: New Line Residential Home is situated about four miles from Bradford City centre. The home is on a main bus route from the city centre and is conveniently situated close to the shops and other facilities in the local area. There is also a large garden for the residents to enjoy, and a car park available. New Line is a detached adapted property, which is presently registered to care for sixteen residents in both single and double bedrooms. All the communal areas used by the residents including the dining room and lounges are situated on the ground floor of the home, and toilet facilities are conveniently situated throughout the building. New Line Residential Home DS0000001283.V276839.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection visit for the year ending 31st March 2006, and was carried out by one Inspector over approximately seven hours. No additional visits to the home have been made. The methods used during this inspection included the examination of records, observation of work practices, discussion (group and individual) with residents, staff and management and a tour of the premises. Comment cards were left for the residents and/or relatives to enable them to share their views of the service with the Commission. Feedback was given to Mrs Angela Wright (assistant manager) at the end of the inspection. Requirements and recommendations made during this visit can be found at the end of the report. What the service does well: What has improved since the last inspection? New Line Residential Home DS0000001283.V276839.R01.S.doc Version 5.1 Page 6 The home continues to make improvements to the environment and blinds have now been fitted to the ground floor bathroom window, which ensures the residents privacy when using the facility. 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. New Line Residential Home DS0000001283.V276839.R01.S.doc Version 5.1 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 New Line Residential Home DS0000001283.V276839.R01.S.doc Version 5.1 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): These standards were not reviewed on this inspection visit. EVIDENCE: These standards were not reviewed on this inspection visit. New Line Residential Home DS0000001283.V276839.R01.S.doc Version 5.1 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): 7,8,9,11 Care plans are completed to a good standard and give clear guidelines to the staff on how to meet the individual resident’s needs. Records and reports indicate that the residents’ healthcare needs are met in line with their care plan and any problems are identified and dealt with at an early stage. However, the manager must remember to notify the Commission of the death of a resident or any significant events, which affect their welfare. EVIDENCE: Care plans have been completed for all residents and cover all aspects of their health and general welfare. The care plans are reviewed at least monthly or sooner if the residents’ needs change significantly. The four care plans reviewed were completed to a good standard and there was evidence in the documentation to show that the residents and/or relatives are involved in the care planning process. All residents are registered with a general practitioner and have access to the full range of NHS services. The input of other healthcare professional is clearly New Line Residential Home DS0000001283.V276839.R01.S.doc Version 5.1 Page 10 recorded in the residents’ care plan and specialist equipment is provided if required. Residents said that they were very pleased with the medical attention they received and confirmed that medical examinations are carried out in their own rooms. The assistant manager confirmed that at present no residents administer their own medication although new admissions to the home would be encouraged to do so if they had the capability. On reviewing the medication system no discrepancies were noted. However, it was recommended that the pharmacist is asked to print the Medication Administration Record (MAR) sheets instead of them being hand written by senior staff. The assistant manager confirmed that policies and procedures about the dying and death of a resident are available to the staff although these could not be found on the day of the visit. Records indicated that the staff had handled the recent death of a resident in a sensitive manner and had offered support to other residents during this difficult period. The assistant manager was reminded that the home is required to report the death of a resident to the Commission as soon as possible, which in this instance it had failed to do. New Line Residential Home DS0000001283.V276839.R01.S.doc Version 5.1 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): 14 Residents are encouraged and supported by the staff team to make informed decisions and choices about their daily lives for as long as it is practical for them to do so. EVIDENCE: The daily routines of the home appear flexible and the assistant manager confirmed that the residents are encouraged to make as many decisions as possible in relation to their lifestyle. One resident in particular said that one of the main reasons he had chosen to live at the home was because it had been made clear to him that his freedom of movement and choice would not be restricted in any way. Residents are encouraged to handle their own financial affairs if they have the capability and are made aware of external agencies that will act in their best interest if necessary. The assistant manager confirmed that the residents are made aware that they can have access to their personal records held by the home in line with the Data Protection Act 1998. New Line Residential Home DS0000001283.V276839.R01.S.doc Version 5.1 Page 12 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): 16,18 Robust complaint and adult protection policies and procedures are in place at the home. However, to protect the residents from any form of abuse the manager must ensure that all members of staff receive adult protection training EVIDENCE: The home has a complaints procedure and the residents confirmed that if they had concerns they would feel able to raise them with the manager or the senior staff team. They were also confident that their concerns would be taken seriously and resolved without them having to make a formal complaint. The assistant manager confirmed that no complaints had been received by the home since the last inspection visit. Policies and procedures are in place in relation to adult protection, however training records indicated that some staff still had not attended an appropriate training course. Staff spoken to appeared aware of the home’s policy on “whistle blowing” and were able to detail what they would do if they felt any practices were not in the residents best interest. New Line Residential Home DS0000001283.V276839.R01.S.doc Version 5.1 Page 13 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): 19,20,21,22,24,26 The home continues to provide a pleasant and comfortable environment for the residents and there is an ongoing programme of refurbishment and renewal. However, to safeguard the residents the manager must ensure that staff follow basic infection control procedures when dealing with clinical waste, and do not leave cleaning substances in areas of the home used by residents. EVIDENCE: Both internally and externally the home is generally well maintained and there is an ongoing programme of refurbishment and renewal. All the communal areas used by the residents including lounges and the dining room are situated on the ground floor of the home, conveniently close to toilet facilities. Bedrooms are located on both floors of the home and consist of both single and double rooms. Bedrooms are well furnished and there was evidence of resident’s personal belongings in every room making them look individual and homely. New Line Residential Home DS0000001283.V276839.R01.S.doc Version 5.1 Page 14 Residents confirmed that the rooms were comfortable and that staff respected their right to privacy by never entering their room without asking permission. Appropriate locks still require fitting to some bedroom doors and the wooden vanity units to at least three wash hand basins require replacing has they are in poor condition. There is a stair lift available to the bedrooms on the first floor and grab rails are fitted throughout the building to assist residents with mobility problems. Bathrooms and toilets are located throughout the home and it was noted that as required in the last inspection report a blind had now been fitted in the bathroom on the ground floor. The standard of fixtures and fittings in all bathrooms and toilets is good although the tiling in one ground floor toilet requires attention. On the day of the visit the general standard of hygiene and cleanliness throughout the building was good. However, in one ground floor toilet soiled incontinence pads had been placed in an open bin and a bottle of bleach left on top of a wall unit, which represents poor practice. New Line Residential Home DS0000001283.V276839.R01.S.doc Version 5.1 Page 15 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): 27,29,30 The staff recruitment and selection procedures are very poor and do not protect the residents from abuse. The manager must explore gaps in the training records of individual members of staff to ensure that they have the training and skill to affectively carry out their duties. EVIDENCE: A rota for the week of inspection showed that sufficient care staff are employed both to meet the needs of the residents and keep the home clean and tidy. Following a staffing arrangement with the previous registration authority the home does not employ cleaning staff and therefore it is the responsibility of the care staff to keep the home clean and free from offensive odours. The present night staffing arrangements is one member of staff on wakeful night duty and one member of staff sleeping-in on the premises. All staff providing personal care are over eighteen years of age and all senior of staff are over twenty-one years of age in line with the National Minimum Standards. The home has a staff recruitment and selection procedure in place, however on reviewing the employment files of five members of staff it was evident the New Line Residential Home DS0000001283.V276839.R01.S.doc Version 5.1 Page 16 procedures were not being followed. No documentation at all could be found for two staff and in a further two instances only one written reference had been received prior to staff commencing employment. The references for another member of staff had not been received until two months after she commenced work at the home and it was evident that the manager had not explored gaps in her employment record. At least one member of staff had been employed prior to a Criminal Record Bureau (CRB) check being obtained although this figure may be higher as some employment documentation could not be found. The assistant manager acknowledged the shortfalls in the recruitment and selection procedures and confirmed that the matter would be addressed. The assistant manager confirmed that staff training continues to be encouraged at the home and all staff receive at least three paid training days per year. However, the training records showed gaps in the training needs of a number of staff and indicated that some staff had not attended a moving and handling refresher course since 2001/02. In addition, dementia care training has still to be arranged, and there was little evidence to suggest that staff had received training in infection control or food hygiene. The assistant manager felt that the training records might not be up to date although confirmed that the manager recently carried out a full staff-training audit as recommended in the last inspection report National Vocational Qualification (NVQ) training is ongoing at the home; however at present less that 50 of the care staff team have a achieved NVQ at level two or equivalent. New Line Residential Home DS0000001283.V276839.R01.S.doc Version 5.1 Page 17 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): 31,33,35,36,38 It would appear that the manager is finding the day-to-day management of two registered services more difficult than first anticipated, resulting in some poor practice issues being highlighted for the first time in this report. The proprietor and manager are taking action to address the matter and at the present time the standard of care/services received by the residents has not been affected. However, to ensure that standards of care within the home are maintained and the residents protected, the proprietor must now complete a monthly report on the home’s conduct and supply a copy to the Commission. EVIDENCE: Mrs Tracey Yeadon has been the registered manager of Newline Residential Care Home for a number of years and has achieved the Registered Managers’ Award. Mrs Yeadon is also the registered manager of Anewline Home Care New Line Residential Home DS0000001283.V276839.R01.S.doc Version 5.1 Page 18 Services, which is owned by the same proprietor but operated from separate premises. Although the manager continues to provide the staff team with a sense of leadership and direction there is an acknowledgement that running two registered services is proving to be more difficult than originally anticipated. The proprietor confirmed that the home is in the process of recruiting a deputy manager to assist in the management of the service. The assistant manager confirmed that the home is currently introducing a recognised quality assurance monitoring system, which will seek the views of the residents/relatives and other healthcare professionals. To comply with the Care Homes Regulations 2001 the registered provider must also complete a monthly report on the conduct of the home and supply a copy to the Commission. Residents confirmed that they were kept informed of any changes in policies and procedures, which may affect their daily lives and felt that their views and opinions were listened to and valued. Staff meetings are held on a regular basis to ensure information is made available to the staff team, and formal one-to-one supervision continues to be held at least every two months in line with the National Minimum Standards. Residents and/or relatives are encouraged to manage their own financial affairs if at all possible although the home will hold money in safekeeping if requested to do. Only senior staff deal with the residents’ finances and receipts are always obtained for purchases made on their behalf. Policies and procedures are in place to ensure the health and safety of the residents, visitors and staff and they are reviewed on a regular basis to ensure that they meet with present legislation. Concerns were raised regarding the methods used for transferring residents in wheelchairs, as five out of the six wheelchairs seen on the day of the visit did not have footrests fitted. In addition, the moving and handling assessment for one resident was not specific, and did not provide the staff with clear guidelines on how to safely transfer her without the risk of injury. No record could be found to indicate that the portable appliances in use at the home had been tested in the last year and therefore this matter must be addressed. New Line Residential Home DS0000001283.V276839.R01.S.doc Version 5.1 Page 19 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 2 3 X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 New Line Residential Home DS0000001283.V276839.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? 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. 2. 3. 4. Standard OP11 OP18 OP21 OP24 Regulation 37 (1)(a) 18 23 23 Requirement The registered manager must give notice to the Commission of the death of resident. The registered manager must ensure that all staff receive adult protection training. Ground floor toilet – tiling requires attention. Bedrooms – The vanity units identified on the day of inspection require replacing. Appropriate locks require fitting to all bedroom doors. (Outstanding from last inspection report – timescale 31/12/05 not met). The registered manager must ensure clinical waste is stored appropriately. The registered manager must ensure that all members of staff follow COSHH policies and procedures. The registered manager must ensure that the staff recruitment and selection procedure is robust. The registered provider must prepare a monthly report on the DS0000001283.V276839.R01.S.doc Timescale for action 31/03/06 31/05/06 31/03/06 31/05/06 5. OP26 16(2)(k) 31/03/06 16(2) 6 OP29 19 02/02/06 7 OP36 26 31/03/06 New Line Residential Home Version 5.1 Page 21 8 OP30 18 9 OP38 13 conduct of the home and supply a copy to the Commission. The registered manager must 31/05/06 ensure that all staff receive the training they require (including refresher courses) to carry out their duties affectively. The registered manager must 31/03/06 ensure that all moving and handling plans are appropriate to the needs of the individual resident. Footrests must be fitted to all wheelchairs. All portable electrical appliances must be tested at least annually. 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 OP9 OP28 Good Practice Recommendations It is recommended that the pharmacist is asked to print the MAR sheets instead of them being hand written by senior staff. The registered manager should ensure that at least 50 of the care staff team achieve a NVQ at level two or equivalent. New Line Residential Home DS0000001283.V276839.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 New Line Residential Home DS0000001283.V276839.R01.S.doc Version 5.1 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!