Inspection on 21/07/05 for New Line Residential Home

This inspection was carried out on 21st July 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

New Line Residential Home 16/07/07

New Line Residential Home 15/08/06

New Line Residential Home 02/02/06

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 BD10 9AS Lead Inspector Steve Marsh Unannounced 21st July 2005 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 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 J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service New Line Address 28 New Line Greengates Bradford BD10 9AS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01274 616631 01274 617007 Mrs Angela Copley Mrs Tracey Yeadon Care Home Only 16 Category(ies) of Old Age (11) Dementia (4) Physical Disability registration, with number (1) of places New Line Residential Home J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 05/10/04 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 J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection for the year 2005/06, and was carried out by one Inspector over a period of about eight hours. The last inspection of this service was in October 2004 and the main purpose of this visit was to assess the progress made in meeting the requirements and recommendations highlighted in the inspection report. The methodology used in this inspection included the examinations of records, observation of work practices, discussions with resident and staff and a tour of the building. Comment cards were provided for the residents and/or their relatives to enable them to share their views of the service with the Commission; comments received in this way will be fed back to the registered manager of the home without revealing the identity of the respondent. People living at the home confirmed that they prefer to be referred to as residents and not service users in inspection reports. This was the Inspectors first visit to New Line Residential Home and therefore he would like to take the opportunity to thank the manager, members of the staff team and residents who participated in the inspection process for their co-operation. Feedback was given to Mrs Yeadon (registered manager) at the end of the visit. Requirements and recommendations from this inspection are detailed at the end of the report. What the service does well: The home provides a safe and comfortable environment for the residents and all concerns/complaints are taken seriously, and action taken to resolve matters. The manager and members of the staff team are approachable, have a caring attitude and create a homely atmosphere for the residents. New Line Residential Home J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 6 The admission procedure for the home is thorough and the manager will not admit residents unless she feels that the staff team can provide the level of care/service they require. The resident’s healthcare needs are met, and any problems are identified at an early stage and a referral made to the appropriate professional agency i.e. general practitioner, district-nursing service. Members of staff encourage the residents to make as many decisions as possible in relation to their daily lives, and activities and outings are organised in line with their wishes. What has improved since the last inspection? What they could do better: The manager needs to ensure that all members of the staff team receive dementia care training, and encourage additional members of staff to commence studying for a National Vocational Qualification (NVQ) at level two or above. The manager should also consider carrying out a full staff training audit and providing additional members of night staff with first aid training. The manager must ensure that the maintenance issues highlighted in the statutory requirement section of the report are addressed within the timescales set. New Line Residential Home J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 7 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 J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection New Line Residential Home J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,4,5 Residents are provided with sufficient information to enable them and/or their relatives to make an informed decision about the home. The admission procedure is good and includes pre-admission assessment visits, introductory visits and trial periods if appropriate. EVIDENCE: The manager is reviewing the homes statement of purpose and service user guide and a copy will be made available to the Commission on completion. The records showed that pre-admission assessment visits are carried out to see prospective residents, and the needs identified during this visit are reflected in their initial care plan. The manager confirmed that the majority of admissions are planned although the home will respond to crisis situations and take emergency admissions providing the staff team are able to meet their needs. In addition to the pre-admission assessment visit, residents and/or their relatives or representatives are also invited to visit the home prior to New Line Residential Home J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 10 admission, to view the accommodation, meet the staff and other residents and stay for a meal if they wish to do so. Residents confirmed that the staff had been very helpful when they or their relatives had initially visited the home looking for a place, had shown them around, answered any questions and provided general information. Staff training is encouraged to meet the needs of the residents, however, it was noted that although the home is registered to care for four residents with dementia the care staff had not received specific dementia care training, and therefore this matter must be addressed. Residents are also able to move into the home for a trial period to enable them and/or their relatives make an informed choice about their long-term future. Although it is acknowledged that for some prospective residents diagnosed with dementia this might not be appropriate as they may become more confused and disorientated. New Line Residential Home J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Records and reports about the resident’s welfare show that their healthcare needs are met and any problems are identified at an earlier stage and a referral made to the appropriate professional agency i.e. general practitioner, district nursing service etc. EVIDENCE: Care plans have been completed for all residents and there is sufficient evidence in the documentation to show that the residents and/or their relatives are involved in the care planning process. The care plans looked at were clear, easily understood and contained both the healthcare and social needs of the residents as well as a good life history. In addition the care plans also included risk assessments for specific areas of concern, and guidance to the staff on how to manage the risk. The manager confirmed that the care plans are reviewed on monthly basis or sooner if the needs of individual residents change significantly. All the residents are registered with a general practitioner and have access to the full range of NHS services. New Line Residential Home J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 12 The home has good working relationships with other healthcare professionals i.e. general practitioner, district nurses etc and the residents confirmed that prompt medical attention was always provided if required, which they found reassuring. The manager confirmed that relatives are kept informed of any changes in the resident’s general health and are encouraged to go with them on outpatient visits etc if at all possible. All medical examinations are carried out in the resident’s own bedroom, and it was obvious through observation and discussion that the staff treat the residents with respect, and maintain their dignity when assisting them with personal care. As required in the last inspection report the manager has introduced a formal assessment tool to assist in identifying residents who may be at risk of developing pressure sores, and the equipment required for the prevention of pressure sores is provided if required. At the present time no residents administer their own medication but the manager confirmed that new admissions to the home would be allowed to do so if they had the capability. The staff team monitor the general health of residents taking long-term medication, and on reviewing the medication system in place no concerns were raised. New Line Residential Home J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 The home offers a range of social and leisure activities, and residents are encouraged to make informed decisions about their lifestyles. Meals appear nourishing and take into account the likes and dislikes of the residents. EVIDENCE: The daily routines of the home appear flexible and are based around the needs of the residents. The home does not employ an activities co-ordinator and therefore it is the responsibility of the care staff to organise activities, outings, and entertainment for the residents. A weekly programme of activities is on display, although the manager confirmed that this is subject to change depending on the needs of the residents. In addition at least four outings per year are arranged to either the coast other places of interest. New Line Residential Home J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 14 Residents spoken to on the day of the visit appeared very happy with the level of activities/outings organised and confirmed that they were able to decide where they wanted to go on trips etc. The residents also confirmed that the manager and staff involve them in all the fund raising events held at the home and they recently helped to organise the summer fayre. The residents also said that prior to moving into the home many of them had lived locally and therefore they like to keep in touch with local news and whenever possible continue to use the shops and other facilities in the area. Residents are able to see visitors in their own room if they wished to do so and confirmed that visitors were always made to feel welcome and offered light refreshment. The meals at the home where described by the residents as very good in both quality and presentation and they confirmed that alternative was provide if they did not like what was on the menu. Residents requiring assistance/prompting with their meals receive the support and assistance needed to ensure that they eat a nutritious and balanced diet. Hot and cold drinks are freely available to the residents both day and night. New Line Residential Home J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Robust complaint and adult protection policies and procedures ensure that the residents are listened to, and protected from any form of abuse. EVIDENCE: The home has a complaints procedure and the residents spoken to said that they were aware of the procedure and knew what to do if they were unhappy with the standard of care/service they received. The manager confirmed that no complaints have been received since the last inspection visit. Policies and procedures are in place at the home in relation to adult protection and training and staff training has been provided through a distant learning training agency. Members of staff confirmed that they were aware of the homes policy on “whistle blowing” and their responsibility to safeguard the residents from any form of abuse. The manager is also aware of the Protection Of Vulnerable Adults register and the implications this may have on the homes staff recruitment, selection and disciplinary procedures. New Line Residential Home J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 16 New Line Residential Home J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 17 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 standard(s) 19,20,21,22,24,25,26 The home provides a pleasant and safe environment for the residents and there is an ongoing programme of refurbishment and renewal to ensure that standards are maintained and improved. Requirements made in this report relating to the environment must be completed within the timescales set, to ensure the health, safety and privacy of the residents. EVIDENCE: Internally and externally the home is well maintained and the manager confirmed that there is an ongoing programme of refurbishment and renewal. All the communal areas used by the residents including the lounges and dining room are situated on the ground floor of the home, conveniently close to toilet facilities. New Line Residential Home J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 18 Bedrooms are located on both floors of the home and consist of both single and double rooms and there is a stair lift available to the accommodation on the first floor. Bedrooms are well furnished although some would benefit from decorating, as part of the homes ongoing programme of refurbishment. Residents are encouraged to bring personal possessions into the home, which makes each room look individual and homely. Residents spoken to on the day of the visit said that they were very happy with the standard of accommodation, and the fact that they had been able to furnish their rooms with personal possessions had made the move into residential care easier. The manager acknowledged that there was a strong smell of urine in one bedroom, however she confirmed that the staff are aware of the problem, and steps are being taken to address the matter. Appropriate locks still require fitting to some bedroom doors and radiator guard still require fitting to some radiators. In addition in at least two bedrooms and a first floor bathroom, window restrictors require fitting, and a blind is required in the ground floor bathroom to ensure the residents privacy when using the facility. Handrails and grab rails are available as required and the emergency call system covers all areas of the home. With the exception of the one bedroom mentioned above the home was clean and tidy on the day of the visit and free from offensive odours. New Line Residential Home J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Residents are supported and protected by a robust staff recruitment and selection procedure, which includes Criminal Record Bureau (CRB) checks. Staffing numbers and the experience/skill mix within the staff team ensures that the needs of the residents are met. However, the manager must continue to ensure that the time spent by the care staff on cleaning, laundry and cooking duties does not affect the standard of care/service received by the residents. EVIDENCE: A rota for the week of inspection was taken which 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 agreement 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 manager confirmed that the care staff hours have been increased, to ensure that they are able to this undertake these additional duties without affecting the standard of care/service received by the residents. New Line Residential Home J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 20 However, the situation must be kept under constant review and the manager must ensure that staffing levels are at all times are kept in line with the dependency levels/needs of the residents. There appears to be a good skill mix within the care staff team and all members of staff providing personal care are over eighteen years of age in line with the National Minimum standards. The home also has a very stable staff team and it was noted that only one new member of care staff has been employed since the last inspection visit in October 2004. The staff recruitment and selection procedures are thorough and the manager confirmed that all new members of staff receive induction and foundation training. There is also an expectation that all members of the care staff team will achieve a National Vocational Qualification (NVQ) at level two or above depending on the post they hold. However at the present under 50 of the care staff team have achieved a NVQ at level two, with six members of staff already having achieved the qualification and a further two currently on the training course. The manager confirmed that she had recently completed the NVQ assessor award and therefore may provide this training in-house in the future. Additional training both to meet the needs of the residents and for personal development is encouraged, although it was recommended to the manager that she carry out a full staff training audit so at any gaps in training are easily identified. New Line Residential Home J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,38 The home is well run and the manager provides good leadership to the staff team and ensures the resident’s rights are protected and their needs are fully met. Policies and procedures are in place to ensure the health and safety of the residents, visitors and members of the staff team. EVIDENCE: Mrs Tracy Yeadon has been the registered manager of New line Residential Home for a number of years, and has achieved the Registered Managers Award. Mrs Yeadon appears to communicate a clear sense of direction and leadership to the staff team, and staff confirmed that she has an open and approachable management style. New Line Residential Home J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 22 Members of staff also said that they enjoyed working at the home, and that all the staff work together as a team for the benefit of the residents. There are clear lines of accountability within the home, with each member of the senior staff team being designated specific areas of responsibility The manager ensures clear channels of communication with the staff by holding staff meetings and one to one supervision is carried out with individual members of staff on a two monthly basis, in line with the National Minimum Standards. In addition the manager also works within the home on a daily basis and therefore is on hand to deal with any quires/concerns raised by either the staff or residents. Policies and procedures are in place to ensure the health and safety of the residents, visitors and members of the staff team, which are reviewed audited on an annual basis by an external agency to ensure that they comply with current legislation. A t the present time five members of the care staff team including one member of the night staff hold a first aid certificate. It was however recommended to the manager that additional members of the night staff receive first aid training to ensure that they are able to affectively manage emergency situations. New Line Residential Home J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 2 3 x 2 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 Standard No 16 17 18 Score 3 x 3 3 3 x x x 3 x 3 New Line Residential Home J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 24 Yes 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. Standard OP4 Regulation Requirement The registered manager must ensure that members of care staff team receive training in dementia care. Bathrooms -- restrictors must be fitted to all windows. A blind is required to the ground floor bathroom window. Bedrooms -- appropriate locks require fitting to all bedroom doors. Radiator guards must be fitted to all radiators. A minimumof 50 of the care staff team must have a NVQ at level two (or equivalent) by the year 2005. Timescale for action 31/12/05 2. OP21 30/09/05 3. 4. 5. OP24 OP25 OP28 31/12/05 31/10/05 31/12/05 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 OP30 OP38 Good Practice Recommendations It is recommended that a training audit is carried out to identify gaps in the individuals traing needs, and to assist when planning future training programmes. It is recommended that additional members of night staff J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 25 New Line Residential Home receive training in first aid. New Line Residential Home J52 J03 S1283 Newline V197220 210705 Stage 4.doc Version 1.40 Page 26 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. 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