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Inspection on 11/01/06 for Newbury Manor Nursing Home

Also see our care home review for Newbury Manor Nursing Home for more information

This inspection was carried out on 11th January 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home benefits from the motivation and commitment of both the owner and the manager. All of the staff seen during the inspection were positive and friendly. The home provides an excellent activities programme for all of the residents. Some of the residents had been to the pantomime the previous evening and said that they had had "a very enjoyable time, they always take us somewhere nice". The health and safety officer at the home takes a pro active approach to risk assessment and risk reduction, and is very enthusiastic in her approach she also recently completed training to enable her to deliver fire safety training at the home. The home is welcoming and is pleasantly decorated, it also has an active refurbishment programme in place to ensure that the environment is maintained to a good standard.

What has improved since the last inspection?

The home has converted a bathroom into a shower room thus making it far more accessible for service users. In the kitchen steps have been taken to improve the noise from the large extractor fan in room 29 with the installation of 3 inspection hatchways. The manager has taken active steps to meet most of the requirements from the previous inspection.

What the care home could do better:

There are very few requirements made during this inspection. The manager still needs to work with the staff in ensuring that all of the residents needs are reflected in their individual care plans and that all assessment documentation is completed.

CARE HOMES FOR OLDER PEOPLE Newbury Manor Nursing Home Newbury Lane Oldbury West Midlands B69 1HE Lead Inspector Mrs Mandy Beck Announced Inspection 11th January 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 Newbury Manor Nursing Home DS0000004864.V270051.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. Newbury Manor Nursing Home DS0000004864.V270051.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Newbury Manor Nursing Home Address Newbury Lane Oldbury West Midlands B69 1HE 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) 0121 532 1632 0121 533 0727 Superior Care (Midlands) Limited Susan Tompkins Care Home 47 Category(ies) of Old age, not falling within any other category registration, with number (47) of places Newbury Manor Nursing Home DS0000004864.V270051.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: nil Date of last inspection 13th September 2005 Brief Description of the Service: Newbury Manor is a purpose built home which was originally registered in 1997. The current registered persons took ownership in February 2002. The property is registered to provide personal and nursing care to a maximum of forty seven older people. The home has a large car park to the front of the building. The garden area surrounds three sides of the home with a paved area and seating. The accommodation is provided on two floors accessed by two passenger lifts and consists of thirty four single en suite bedrooms, 1 single bedroom with no ensuite and six double en suite bedrooms. All bedrooms are fully furnished and tastefully decorated. The home has one lounge and two dining rooms on the ground floor. There is also a lounge and dining area of the first floor. There are sufficient toilets and bathrooms throughout the home. Newbury Manor Nursing Home DS0000004864.V270051.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection and was carried out by one inspector on one day between the hours of 09.30 and 16.00 hours. During the inspection a tour of the premises was carried out and discussions with staff and residents were conducted. The focus of the inspection was to assess the home’s progress in meeting the outstanding requirements from the previous inspection and to look at specific key standards and the home’s progress towards meeting the National Minimum standards for older people. Information was used from the home pre inspection questionnaire and responses from 42 relative/service user comment cards. Residents individual files were case tracked, this included looking at their assessments, care plans and delivery of care. Two staff files were seen to ensure that a previous requirement had been addressed. The inspector would like to thank all of the residents and staff for a pleasant day and a positive inspection. What the service does well: What has improved since the last inspection? The home has converted a bathroom into a shower room thus making it far more accessible for service users. In the kitchen steps have been taken to improve the noise from the large extractor fan in room 29 with the installation of 3 inspection hatchways. The manager has taken active steps to meet most of the requirements from the previous inspection. Newbury Manor Nursing Home DS0000004864.V270051.R01.S.doc Version 5.1 Page 6 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. Newbury Manor Nursing Home DS0000004864.V270051.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 Newbury Manor Nursing Home DS0000004864.V270051.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): No standards in this section were assessed at this inspection EVIDENCE: Newbury Manor Nursing Home DS0000004864.V270051.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, Care plans are in place for all residents and generally met most of their needs. Evidence is available to demonstrate that the resident’s health care needs are being met. EVIDENCE: There are care plans in every resident’s file that addresses how their care is to be managed. It was apparent that not all of the assessment information is being transferred to a current care plan for some of the residents. One resident’s assessment indicated that they suffered with constipation and needed medication to manage their symptoms but there was no care plan to record appropriate intervention for the resident. Risk assessments are in place that address falls, moving and handling, pressure sore risk and nutrition. All care plans are reviewed on a monthly basis and involve both care staff and the resident and/or their representative. Each resident has access to specialist health care services including medical, nursing, dental and optical care according to their individual need. Comments from service users about their health care included “if I’m not well they don’t Newbury Manor Nursing Home DS0000004864.V270051.R01.S.doc Version 5.1 Page 10 hesitate to call the doctor”, “would like to mobilise more but have spoken to Sue the manager and this has improved since the new activity organiser has started”. Other comments from relatives include “I am very happy with the standard of care provided”, “the matron and her staff are friendly and caring”, “my mother has been a resident for over three years during this time she has received unstinting care and attention”. Newbury Manor Nursing Home DS0000004864.V270051.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): 14,15 All residents are encouraged to exercise choice and control over their lives. Residents are provided with healthy, wholesome meals in pleasant surroundings this helps make mealtimes a relaxing affair for the residents. EVIDENCE: The manager encourages all of the residents to take part in all aspects of life at the home. Some of the residents were having difficulty completing the comment cards for this inspection the manager arranged for an advocate to visit the home to help those residents complete their cards. Residents are encouraged to bring their personal possessions with them, this is generally agreed before the resident’s admission. The home provides three meals a day with supper late evening. Every resident is offered a choice and the kitchen staff demonstrated a clear understanding of each residents likes and dislikes. There is always an alternative choice if residents dislike anything on the menu. On the day of inspection residents were being served liver and bacon rolls or macaroni cheese with mashed potatoes and mixed vegetables, followed with a dessert of pineapple upside down cake and custard. “the food is always nice I never remember what I order and it’s a surprise when it comes”. Generally all of the comments about the food were positive but some other comments included “the food could be Newbury Manor Nursing Home DS0000004864.V270051.R01.S.doc Version 5.1 Page 12 of a better standard and hotter”, “sometimes the residents need coaxing to eat, the food goes cold and is then taken away because some have dementia”. The cook has appropriate information located within the kitchen to provide any specialist diet that may be required by each resident. Meals are served mainly in the two dining rooms located on the ground floor, other residents prefer to eat their meals either in the lounge or in their own bedrooms. Some residents said that it “is more quieter in here the dining room gets too busy”, “I eat my meals in my room because I like it here I can go to the dining room if I want to I just don’t”. Newbury Manor Nursing Home DS0000004864.V270051.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Residents and their relatives can be assured that their complaints will be listened to and dealt with effectively. Service user are protected from abuse. EVIDENCE: During the past twelve months the home has received three complaints, all of these complaints were dealt with appropriately. The home has a comprehensive complaints policy and procedure and it informs residents and their relatives how to make a complaint, who will deal with it and the timescale that the complaint will be responded to. The home keeps a record of all complaints that have been made and this includes all action taken where appropriate. Residents are also informed of how to contact the Commission for Social Care Inspection should they wish to make a complaint. The home has robust procedures and policies in place to protect residents from abuse. The policies have been written in conjunction with the area adult protection unit and Department of Health guidance “No Secrets”. The majority of the staff have undertaken training to increase their awareness of adult abuse. Newbury Manor Nursing Home DS0000004864.V270051.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The environment is well maintained and pleasantly decorated throughout providing residents with a relaxing homely environment. EVIDENCE: A tour of the premises was carried out this was to assess the progress in meeting outstanding requirements from the previous inspection. The home has recently converted one of the bathrooms on the ground floor into a walk in shower room, most of the residents prefer to be showered and this addition has proved popular with them. A number of bedrooms were seen and they were all pleasantly decorated and residents are encouraged to help choose their decoration where possible. There were plenty of personal possessions making each room feel individualised and relaxing. Previously the noise from the extractor fan in the kitchen had an impact on the noise levels in bedroom 29, the home has taken steps to address this with the Newbury Manor Nursing Home DS0000004864.V270051.R01.S.doc Version 5.1 Page 15 installation of three inspection hatchways. The noise within the room appears to be dramatically reduced although not totally eliminated. The staff room does not have appropriate storage for all staff to secure their belongings whilst on duty, lockers were seen to be damaged and broken and staff reported that keys had gone missing making some lockers inaccessible. This needs to be addressed to reduce the risk of items going missing, and to reduce staff anxiety about leaving their belongings whilst on duty. Newbury Manor Nursing Home DS0000004864.V270051.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the standards were assessed in this section EVIDENCE: Staff files were examined as a result of previous requirements these were found to be met in full however the manager must ensure that all staff files have a photograph. Newbury Manor Nursing Home DS0000004864.V270051.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): 33,35 Residents live in a home that is run in their best interests and their security is maintained at all times. EVIDENCE: The manager is embarking upon the Investors in People award to improve the quality assurance and help them with a systematic cycle of planning – action – review. The home conducts residents surveys and also seeks the views of stakeholders in the community this includes, G.P’s, Occupational Therapists, community mental health nurses and dietician. The manager now needs to collate this information and publish the findings for all interested parties. The staff at the home demonstrate commitment to practice and lifelong learning with all registered nurses being encouraged to maintain their professional development. Newbury Manor Nursing Home DS0000004864.V270051.R01.S.doc Version 5.1 Page 18 The home manages small amounts of money for each resident such as paying for their newspapers and hairdressing if required. Written records of all transactions are maintained and no monies are pooled and are managed individually, records are kept but there were some missing receipts. The home provides secure facilities for money and valuables. Newbury Manor Nursing Home DS0000004864.V270051.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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X x Newbury Manor Nursing Home DS0000004864.V270051.R01.S.doc Version 5.1 Page 20 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 The registered persons and manager must ensure that residents’ care plans reflect all needs, risks and special requests (previous timescale 01/10/05 not met) The registered persons and manager must replace the floor covering in the small ground floor dining room. (previous timescale 01/11/05 not met) The registered persons and manager that there are enough staff lockers available for staff to be able to secure their belongings during their shift, as outlined in the staff handbook The registered persons and manager must ensure that all staff have a photograph on their individual staff file, as indicated in paragraph 1 of schedule 2 The registered manager should make available the results of the recent residents survey for residents and other interested parties Timescale for action 30/03/06 2 OP20 23(2)(d) 01/06/06 3 OP38 23(3)(ii) 30/03/06 4 OP29 19 (b) 01/03/06 5 OP33 24(2) 30/03/06 Newbury Manor Nursing Home DS0000004864.V270051.R01.S.doc Version 5.1 Page 21 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 Refer to Standard OP30 Good Practice Recommendations The registered persons and manager are advised to consider dementia care and person centred care training for all staff, so they can be assured they are meeting residents needs with dementia. Newbury Manor Nursing Home DS0000004864.V270051.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Newbury Manor Nursing Home DS0000004864.V270051.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. 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