Inspection on 22/08/06 for Newbury Manor Nursing Home

This inspection was carried out on 22nd August 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.

Other inspections for this house

Newbury Manor Nursing Home 12/05/10

Newbury Manor Nursing Home 09/02/10

Newbury Manor Nursing Home 08/07/09

Newbury Manor Nursing Home 11/08/08

Newbury Manor Nursing Home 11/01/06

Newbury Manor Nursing Home 13/09/05

Newbury Manor Nursing Home 09/03/05

Newbury Manor Nursing Home 03/08/04

Newbury Manor Nursing Home 28/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Maple Lodge

Polesworth Group 32 Station Road

Heathlands

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

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

CARE HOMES FOR OLDER PEOPLE Newbury Manor Nursing Home Newbury Lane Oldbury West Midlands B69 1HE Lead Inspector Jayne Fisher Unannounced Inspection 22nd August 2006 08:30 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.V308922.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. Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 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.V308922.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 11 January 2006 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 situated close to Oldbury town centre. Access to the Midlands motorway network is located within one mile. The home 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 patio area and seating. The accommodation is provided on two floors accessed by two passenger lifts and consists of thirty-three single en-suite bedrooms and seven double en-suite bedrooms. All bedrooms are fully furnished and tastefully decorated. The home provides two lounges and a dining room on the ground floor and a lounge on the first floor. There are sufficient assisted toilets and bathrooms throughout the home. Ramps for ease of access and egress to the front and rear of the building. The home provides an excellent range of activities for residents and organises entertainers and events. A statement of purpose and service user guide are available to inform residents of their entitlements. The charges for accommodation range between £336 to £495, this information was obtained from the pre inspection questionnaire completed by the home’s manager on 4 August 2006. There are additional charges for hairdressing, toiletries and newspapers. Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 08:30 a.m. and 19:00 p.m. The purpose of the inspection was to assess progress towards meeting the key national minimum standards and towards addressing items identified at previous inspection visits. A range of inspection methods were used to make judgements and obtain evidence which included: interviews with the registered manager, registered provider and six staff. Seventeen residents completed feedback questionnaires assisted by an advocate; residents were also spoken to in order confirm responses and also in order to make evaluations. Unfortunately, no questionnaires were sent by the Commission for Social Care Inspection to relatives, however three relatives were interviewed during the visit. Three residents’ were selected for case tracking purposes. This process included the perusal of their records examples being assessment documentation, care plans, daily entries, healthcare visits and risk assessments. Interviews were also held with a key worker. Several residents were either interviewed or chatted to. It was not appropriate for formal interviews to take place with a number of residents therefore inspector relied upon brief chats, observations of body language and interaction between staff and service users. A tour of the premises was undertaken which included visits to all communal areas and random sampling of residents’ bedrooms. Two meal times were observed and medication management and systems were assessed. Staff personal files were also accessed. What the service does well: All statements made during interviews and via feedback questionnaires were positive regarding staff and the quality of nursing and personal support given. Comments made included “they are very good to me; I can’t say anything else”, “it’s ever so nice, I had a shock when I saw my bedroom, it’s so lovely”, and “I have got some lovely carers and we always have a laugh and a joke”. This was a positive inspection visit which confirmed that the owner and manager of the home continue to remain dedicated to raising standards and are supported in doing so by a stable team of qualified and well trained staff. Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 6 Residents’ health and personal care needs are very well met and high priority is given to maintaining the dignity and privacy of residents ensuing that they are treated with respect. Staff were seen to respond patiently to requests made by residents and relatives through out the day. There are excellent opportunities for residents with regard to meeting their social, religious and recreational interests and needs through a range of stimulating and varied activities within the home and local community. Some residents enjoyed an annual holiday to Blackpool this year with the support from the manager and staff who accompanied them. Mealtimes are relaxed and unhurried. Strenuous efforts are made by staff to accommodate residents’ individual food preferences and choices. There are good procedures in place to protect residents from abuse and the manager ensures that both residents and visitors are supported in making any concerns known which are dealt with promptly and in a proactive manner. All residents and visitors who were either interviewed or completed comment cards felt able to raise any concerns with staff and the manager. The premises is safe, comfortable and decorated to a good standard. It was seen to be clean, tidy and free from any offensive odours. Communal areas are bright and welcoming. Residents are able to bring their personal possessions with them and small items of furniture making their bedrooms relaxing and homely. Both residents and staff are supported by a dedicated and caring manager who is highly skilled and experienced. The atmosphere through out this visit was relaxed and friendly with both management and staff interacting positively with the inspection process. What has improved since the last inspection? What they could do better: Care planning is generally good only slight ‘fine tuning’ is necessary to ensure that staff are provided with all of the relevant information. Overall there are good arrangements in place for the management of medication, however recording systems need improvement in order to ensure residents are offered suitable safeguards and to reduce any potential for risk. Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 7 There are only a couple of items relating to health and safety practice and premises which require attention. 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.V308922.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 Newbury Manor Nursing Home DS0000004864.V308922.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The overall outcome for this group of standards is judged to be good. No resident moves into the home without having had his/her needs assessed or being assured that these will be met. EVIDENCE: A service user who was admitted to the home in June 2006 was case tracked in order to determine compliance with these standards. There was a copy of the placing officer’s care plan received prior to admission and senior staff had carried out an assessment of need in order to ensure that needs could be met. In addition there was also a ‘prospective new service user’ form completed in order to judge whether or not staff have the skills to meet the residents’ needs. The resident was admitted as an emergency and therefore did not have time to visit the home but the manager reported that family had visited prior to admission. There was a letter from the manager confirming that the home could meet assessed needs as is required by the Care Homes Regulations 2001 (although this needed to be dated by the manager). Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 10 Interviews with the key worker confirmed that the resident had settled in well confirming that the assessment had been thorough and successful. Visiting relatives were interviewed who had two weeks ago placed their mother at the home. They stated “she’s settling in and is happy”. Eleven residents who completed comment cards stated that they felt they had sufficient information prior to their admission to help them make a decision about whether or not they wished to live at Newbury Manor. No resident who completed a comment card made any negative statements. One person stated “the manager saw me in hospital and then I came for a visit. My daughter told me a lot of information from the service user guide”. Newbury Manor Nursing Home DS0000004864.V308922.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The overall outcome for this group of standards is judged to be good. Residents’ health, personal and social care needs are set out in an individual plan of care, although slight improvements are needed to ensure that all needs and concerns identified are reflected in these documents. There is evidence of good multi-disciplinary working and residents’ health care needs are fully met. Arrangements for the control and administration of medication are generally satisfactory although some areas require improvement in order to ensure there are no risks to residents’ safety. Residents’ feel that they are treated with respect and their right to privacy is upheld. Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 12 EVIDENCE: A sample of care plans were examined and a key worker was interviewed who demonstrated good knowledge regarding the needs of the resident. It was pleasing to see that a range of care plans and associated risk assessments were in place. For example there were care plans in place for mobility, incontinence management, urine infections, sleeping, expressing sexuality, epilepsy, personal hygiene and oral care. There were risk assessments in place for nutrition, continence, moving and handling, tissue viability, falls and the use of bedrails. It was pleasing to see that these are reviewed on a monthly basis. There were also details of service user involvement including review meetings held with the residents, families and social workers. A couple of deficiencies were noted, for example one residents’ assessment on admission stated that they were at risk of choking and required a soft diet. An assessment also indicated that their appetite was poor and the nutritional risk assessment was scored as high risk. The manager stated that recently a food supplement had been requested from the doctor. However, there was no associated care plan. Management and staff stated that they had determined over the last few months that there was no risk of choking, however a risk assessment should have been carried out in the interim as this was a risk identified at the initial assessment. There was no care plan regarding communication or guidelines for staff regarding how to communicate with the resident who has no speech. This is particularly important as the key worker stated that the resident could become distressed because of the inability to communicate. The care plan for nutrition should also include the residents’ likes and dislikes. There was no care plan in place regarding social care needs. Although the care plans had been reviewed in June and August 2006, there was no review carried out in July 2006 and no monthly key worker report. There was ample evidence that health care needs are a priority. For instance there were record sheets within residents’ case files containing details of appointments and outcomes from health care specialists such as ophthalmologists, chiropodists, dentists and doctors. Residents are weighed monthly with records maintained. Care plans contained details of pressure relieving equipment. The manager had recently secured extra funding to provide more staff for one resident who requires more support for therapeutic activities and reduce behavioural problems because of a health related condition. Personal hygiene records are maintained to a good standard. Fifteen residents who completed comment cards stated that they received the medical support they need. One resident stated during interview “I tell the nurses what is wrong and they help me or get the doctor”. Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 13 Generally there are good practices relating to the administration and control of medication. The manager reported that a new pharmacist has recently been sought and a monitored dosage system introduced in order to improve efficiency. Residents are given the opportunity to self administer if they wish and some have chosen to self administer their own inhalers or homeopathic remedies. There is a key holding policy and handover procedure. There was no overstocking of medication and the temperature of the drugs fridge is checked and recorded. A clinical waste contract has been agreed to dispose of unused/ unwanted medications with records maintained. There is an up to date staff signature list in operation. Medications are only managed and administered by the registered nurses. It is positive that care staff who sometimes act as witnesses for the administration of Controlled Drugs have received training from the manager. The main shortfall identified is with regard to the lack of consistent recording in respect of medication administration. Unfortunately, there were a large number of gaps identified on examination of the medication administration record (MAR) sheets. During a two week period there were at over forty gaps counted where staff had either failed to sign their initials to confirm that medication had been administered, or had failed to enter the correct letter code to signify why medication had not been administered. It was possible to determine in most cases, that medication had been given but had not been signed for. Where medication had not been administered the nurse in charge was able to give an appropriate response as to the reason why this had not taken place. On occasions staff had been signing the MAR sheets inadvertently; although medication had been changed (or had ceased) they were still signing for the old and new drug. On one occasion the Controlled Drugs Register had been signed but staff had failed to complete the MAR sheet. There were a couple of instances where staff had entered an unrecognisable letter code such as ‘NA’. Medication received into the home is checked and recorded, however as discussed with the manager the initials or name of the nurse undertaking this task must also be recorded. It was noted that the quantities of short term medications which are received mid cycle such as antibiotics are not recorded. This must be undertaken in order to keeping a running balance of all medications held on the premises and also to ensure that all of the required course is administered to the resident. It is also recommended that an audit and running balance of ‘as and when’ required (PRN) medication is also held. Overall there are good practices relating to residents’ privacy and dignity. For example, residents were seen to be dressed appropriately and well groomed. Blankets are used to promote dignity when residents are sitting in the lounge areas. Staff were observed speaking respectfully to residents’ and giving them choices with regard to meals, where they wanted to sit and whether they wanted to join in activities. Locks were seen in place on toilet and bathroom doors. Toilet and bathroom doors were seen to be closed when in use. The preferred form of address in respect of each resident is determined and Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 14 recorded on their personal file on admission. On one occasion staff were seen to use the hoist to transfer a resident into the dining room rather than a wheelchair. It was reassuring to see that the manager continually makes staff aware that this is not acceptable practice through staff meetings. Minutes from meetings were examined which demonstrated that the manager places an high emphasis on reminding staff to respect residents’ dignity. A couple of issues raised by relatives or visitors in the complaints/compliments book relating to privacy and dignity had received appropriate action and response by the manager. During interviews residents stated that they felt their privacy was respected. All seventeen residents who completed comment cards stated that they felt staff listened and acted upon what they said. One resident was observed to be eating her evening meal at 6.30 p.m. in the dining room on the first floor wearing her night gown. However, it was reassuring that upon discussion she confirmed that this was her chosen routine. Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 15 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): 12, 13, 14 and 15 The overall outcome for this group of standards is judged to be good. Residents are given plenty of opportunities to participate in stimulating and varied activities both in the home and in the community that enrich their lives. Residents enjoy a varied and well balanced diet. EVIDENCE: Residents’ preferred daily routines are recorded in their care plans such as their favoured times for getting up and going to bed. Residents are also asked as to whether they prefer male or female staff which is also fully recorded. There are also ‘life history’ profiles which key workers complete with residents and their families so that important information regarding residents’ interests can be gained. During interviews one resident commented upon how important her faith was and that visitors from her church came to see her every day. There is also a weekly church service held by an ex-member of staff with hymn signing and readings from the bible. Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 16 Activity provision remains excellent. The majority of residents who completed comment cards stated that there were always plenty of activities on offer. Some commented that there were activities offered to them but they chose not to participate. The home employs an activities co-ordinator who works 25 hours per week. During interviews she displayed a keen and enthusiastic approach having a good knowledge of residents’ likes and dislikes being formerly employed as a carer at the home. There is an activities folder and record sheets (although this wasn’t available for inspection on the day as the activities co-ordinator was updating information at home). There are colourful and informative activity boards on both floors. An art and craft collection is on display in the ground floor hallway. This collection consists of items that the residents’ have made with a sessional worker who visits the home on a weekly basis. Activities offered include visiting entertainers, flower arranging, cooking, board games, reminiscence therapy and bingo sessions. Positive comments from residents included “Julie the activities organiser is very good and she loves me to join in and I enjoy taking part”. Residents are offered the opportunity of going on holiday. This year some residents chose to go to Blackpool. One resident stated “We have recently been on holiday with the manager and carers to Blackpool. It was very nice; I wanted to stay an extra week”. Last year some residents had also participated in swimming sessions with certificates of their achievement displayed in the corridor. There are ample opportunities for residents to participate in the local community. The home has its own mini bus and residents are taken on trips and outings to a variety of destinations including Stourport, Haden Hill House, the Science Museum in Birmingham and a local restaurant and cabaret show. Residents are also able to use the minibus to visit their relatives if they wish. There were plenty of visitors through out the day who were greeted warmly by the manager and staff. Relatives who were interviewed were all positive about the care and support given by the manager and staff. There are residents and relatives meetings held which empowers users to exercise choice about their lives and how they wish to be supported. The manager arranged for an advocate to help residents complete comment cards which were sent out prior to this visit which is an excellent initiative. Bedrooms were seen to contain residents’ personal possessions and in some cases their own furniture. Meals and mealtimes are relaxed and unhurried. Despite both cooks being off sick the kitchen assistants coped admirably and were clearly aware of individual residents’ likes and dislikes. There is a four weekly rolling menu which staff stated was composed by the cook in liaison with residents and altered on a seasonal basis. Staff make a concentrated effort to ensure that individual residents’ preferences are catered for. There are two choices at lunch and dinner time however residents can choose to have alternatives as observed on the day of the visit where one resident said that she wanted egg and bacon rather than the two options available which staff provided without Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 17 any complaint or comment demonstrating that this is a regular occurrence. One resident chooses to have steak for his main meal every day which is accommodated. Staff ask residents to choose their options from the menu on the previous day and records are maintained. These records demonstrated that residents can choose to have alternatives and do so on a regular basis. Interviews with staff confirmed their in depth knowledge of residents’ preferences. Residents were seen to be able to exercise choice about whether or not they wished to eat in the dining room, lounge or in their own bedrooms. It was positive that staff were on hand to give assistance at mealtimes to those who required this. Staff were observed sitting feeding residents in a discreet and sensitive manner. The majority of residents who completed comment cards stated that they always or usually liked the meals provided. Positive comments made included “I am always offered a choice”, “I can always ask for something different” and “I always eat my dinner, sometimes I’m too full up to eat all of my tea”. On the evening of the visit one resident asked a carer to fetch her some softer toast which received a positive response. There were only a couple of minor issues identified which may help to raise current standards and further increase residents’ satisfaction. For example, apart from displaying the day’s menu on the notice board in the ground floor dining room there is no other information available to residents for instance regarding the weekly menu. Residents who are confused may benefit from pictorial menus which may help in keeping them informed but also aid them in making choices from the daily menu. At present there are no moulds for pureed diets however, the registered provider stated that this had already been identified as an issue and these would be purchased in order to make meals more appealing. Plastic tablecloths although practical do not always promote a dignified or congenial setting. There were a lack of condiments and other homely touches and it was pleasing to hear that the manager is trying to look at strategies to make meal times pleasing for all residents yet at the same time safe enough for those residents who may be confused. Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 18 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 and 18 The overall outcome for this group of standards is judged to be good. Residents’ and relatives are confident that their complaints will be listened to and acted upon. There are robust systems in place to protect residents from abuse. EVIDENCE: There is a comprehensive complaints procedure in place. No complaints have been received by the Commission for Social Care Inspection during the last twelve months. The Manager has received two complaints and examination of the documentation confirms that a thorough investigation was undertaken and an appropriate response made to the complainants together with an action plan to rectify any issues identified. There is also a compliments and complaints book openly available so that residents and visitors can make any concerns known, anonymously if they so wish. One relative who was interviewed stated that if she had any issues she would always raise them with staff first and that normally within a couple of days appropriate action was taken. All seventeen residents who completed comment cards stated that they knew how to make a complaint. Interviews and comments received from residents included “I would speak to Sue (the manager), I wouldn’t hesitate to say” and “if it was the seniors, I would tell Sue”. During interviews staff gave appropriate responses as to how they would deal with any complaints made by residents. Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 19 Adult protection policies and procedures were not perused during this inspection but have been seen at previous visits and there are no outstanding requirements. During interviews staff gave appropriate responses to how they would deal with any potential incidents of abuse and clearly understood the principles of Whistle Blowing. Examination of the staff training profile confirms that the majority of staff have received training in vulnerable adult abuse awareness. Some of the newer staff still require this training and the manager reported that this had been booked to take place in the near future. The manager has demonstrated in the past a responsible and proactive attitude towards protecting residents and staff. The manager does not act as appointee for any residents in managing their finances and states that families normally deal with any monies. Small amounts are given to the administrator to hold on behalf of residents if necessary. There have been no issues raised in the past with the way in which monies have been held or recorded. There were personal inventories contained within residents’ case files detailing what personal items they have brought into the home with them. Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 20 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 and 26 The overall outcome for this group of standards is judged to be good. Residents’ live in a safe, well-maintained environment. The home is clean, pleasant and hygienic. EVIDENCE: The home employs a handyperson and there is a rolling maintenance programme which on examination demonstrates that any repair works are quickly and promptly dealt with. A tour of the premises was undertaken including visits to a random sample of residents’ bedrooms. It was pleasing to see as required at the previous inspection new flooring has been fitted to the small dining room on the ground floor and new lockers have been purchased for staff to store their valuables. New flooring has also been installed in the first floor lounge area. Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 21 The home is safe in terms of security. The front door is kept locked and accessible by a digital locking system and intercom. The entrance and foyer area is bright and welcoming, displaying a wealth of information for visitors and residents. All communal areas are decorated to a good standard and are well lit and airy. Bedrooms were also seen to be pleasantly decorated and furnished; there were plenty of personal possessions and in some cases residents’ own furniture, making rooms feel individualised and relaxing. There was evidence in residents’ case files that they had been offered the opportunity of holding their own bedroom door key if they so wished. Bedrooms also contained lockable cupboards. A random audit in respect of infection control was carried out. This included viewing a number of bathrooms and toilets. Clinical waste receptacles, paper towels, liquid soap and protective clothing were available in all these rooms or close by. Bathrooms were free from communal items such as nail brushes or face cloths. It was pleasing to see that antiseptic hand wash liquid was available at the entrance to the home for visitors’ use. The laundry was clean and tidy with impermeable walls and flooring. A new washing machine and tumble dryer has been recently purchased. There is a range of protective clothing, liquid soap and water soluble bags for the washing of infected laundry. Staff were seen to be wearing appropriate protective clothing when carrying out domestic tasks around the building and also in the kitchen area. The majority of residents who completed comments cards stated that the home was always fresh and clean. There were no negative comments made. One resident stated “it’s spotless, I can’t say anything about this place it’s lovely”. There were only a couple of minor items requiring attention. In bathroom 2, a small number of tiles were broken around the base to the floor in the shower area. In the first floor kitchenette, grouting around the work surfaces is stained and perished and requires replacing (this was also identified as requiring attention by the Environmental Officer who conducted a food hygiene inspection in November 2005). For other comments regarding food hygiene practice see standard 38. Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 22 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, 28, 29 and 30 The overall outcome for this group of standards is judged to be good. Residents are cared for by a stable and well trained staff team who are deployed in sufficient numbers to meet their needs. There are robust recruitment and selection procedures which offer suitable safeguards for residents. EVIDENCE: Feedback from residents via comment cards and during interviews was positive regarding the nursing and personal support administered by staff. One resident stated during interviews “even though staff are off sick, they do rally round”. Another resident named her favourite support staff and stated “they are very caring”. On examination of the duty rota sufficient staffing levels are being maintained. For example, during the morning eight care staff and one Registered Nurse are deployed and in the afternoon there are seven care staff and one Registered Nurse on duty. At night times there are four carers plus one Registered Nurse. Extra care staff are on duty from time to time in order to support one resident’s needs; the manager is in the process of recruiting extra staff so that this support can be provided on a more consistent basis. Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 23 The home has an activities co-ordinator and a handyperson. Catering hours are provided continually throughout the day to 19.00 hours. Domestic and laundry staff are provided every day. The majority of staff who work at the home have been employed for two years or more. Some staff have worked at the home for the last eight years. Information provided by the manager confirms that the home is exceeding the standards with regard to the number of care staff who are qualified to NVQ II or above. For example, there are thirty three care staff employed, twenty of whom are qualified to NVQ II or above. During interviews staff reported that they were supported and encouraged by the manager to undertake further training. One member of staff stated that they had sought employment at the home in order to further their career and training. The personal file of a new member of staff was examined. This demonstrated that all pre-employment checks were undertaken prior to appointment this included two references from the last employer. A third character reference was also obtained. A health issue had been declared and discussed to the satisfaction of the manager. It was suggested that some reference to this discussion be recorded; a risk assessment not being deemed as necessary in this instance. There was evidence to demonstrate that new staff continue to receive appropriate induction and foundation training. During interviews a staff member spoke about her role as a supervisor involved in inducting new staff and confirmed that this was carried out within the first four to six weeks of their employment. A training matrix is in operation which includes each individual staff members name and courses attended/ due to attend. Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 24 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 and 38 The overall outcome for this group of standards is judged to be good. Residents benefit from a well run home which is managed by a competent and skilled manager. Quality assurance systems are continuing to improve in order to ensure that residents are offered sufficient opportunities to influence service delivery. The registered manager ensures so far as is reasonably practicable, the health, safety and wellbeing of residents and staff. EVIDENCE: There was ample evidence to confirm that Mrs. Thompson is an excellent manager who is respected by both staff, residents and relatives. For example, during the day time a number of relatives were greeted warmly on entering the home by the manager whom they clearly knew well and were able to ask questions about their family member. Residents were also seen to approach the manager’s office on a frequent basis to chat and talk about any of their Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 25 health concerns. Mrs. Tompkins continues to remain highly dedicated to the residents and staff at Newbury Manor and in maintaining high standards with regard to service provision. For example, as manager she works during the day time and also will cover shifts herself at the weekend and night time in order to supervise and support staff. In her own time Mrs. Tompkins recently took a resident to a family wedding at the weekend and was observed during this visit to undertake hands on care tasks such as assisting a resident with eating. Mrs. Tompkins continually updates her knowledge and has recently volunteered and been successfully appointed to participate in a pilot study regarding raising standards in palliative care. There were many positive comments made by residents, visitors and staff regarding the manager including “I think Sue and the nurses really try hard to make you feel comfortable and they do look after your needs”. “Sue will always listen and hear your views, she’s one of the most approachable managers”. Quality assurance systems are continuing to be developed. For example, at the last inspection the manager was asked to make available the results of residents’ surveys and was able to demonstrate that she is currently collating this information. An annual development plan for the home, based on a systematic cycle of planning, action and review also needs to be devised as discussed with the registered provider. During interviews the manager confirmed that the home continues to manage small amounts of money for each resident such as paying for their newspapers and hairdressing if required. No monies are pooled and the manager does not act as appointee for any residents. Financial procedures have been found to be good at previous visits and there are no outstanding requirements. There are good systems in place to protect residents’ health and safety. A sample of maintenance and service records were examined and found to be up to date. For example there is weekly testing of the fire alarm system and regular fire drills; at least four have taken place since 31 December 2005. There is an up to date fire safety risk assessment and a monthly safety checklist completed by the nominated fire warden. Generally there is good accident reporting systems. There was one occasion where an accident report had not been completed but this was quickly identified and rectified. The manager monitors accidents and reminders are sent to staff if any patterns are identified such as falls. There is a training matrix which demonstrates that mandatory training is up to date for the majority of staff. Some training is delivered in-house by staff qualified to do so such as fire safety. Specialist training is on-going such as dementia awareness. Only a small number of improvements are necessary. For example, the fire officer conducted an inspection on 9 December 2005. Recommendations made have been largely complied with although there was still one door wedge found in the small dining room. As discussed, for health and safety as well as fire safety issues this must be fitted with a suitable door closer. Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 26 Food hygiene is generally good with consistent checking and recording of fridge, freezer and cooked food temperatures. During interviews kitchen staff demonstrated good knowledge regarding safe temperatures. High risk food products were seen to be labelled and stored appropriately. Frozen foods were also labelled with the date of freezing. The Environmental Officer conducted a food hygiene inspection on 16 November 2005. The majority of recommendations have been complied except the replacement of the stained and perished grouting in the first floor kitchenette. Other recommendations received appropriate action but continued compliance must also be ensured. For example, whilst according to records maintained, the light diffusers in the kitchen had been cleaned, these now contained another build up of dead insects. There was a small amount of debris on the floor beneath the dish washer. It was pleasing to see that the food probe continues to be calibrated. Two bottles of hazardous substances were seen to be unsecured in the sluice and laundry area and these must be held securely at all times. One item had been decanted into an unlabelled container. Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 27 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 3 X X 2 Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 28 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 is not fully met) To make the following improvements to the control and administration of medication: 1) To improve administration of medication and recording on the medication administration record (MAR) sheets. For example staff must either sign their initials to denote administration, or record a suitable letter code to signify why medication has not been administered. All gaps must be explored with written explanations obtained. 2) The quantities of all medication received by the home must be checked and confirmed in writing along with the date of receipt and the initials of the member of staff receiving the medication. Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 29 Timescale for action 01/01/07 2. OP9 13(2) 01/10/06 3) All handwritten entries written on to the MAR charts must also be double checked for accuracy and signed by a second member of staff. 4) To ensure that MAR sheets are completed accurately with recognised letter codes used to signify when medication is, (or is not), administered instead of symbols which have no legal context. 3. 4. OP26 OP33 13(3) 23(2)(b) 24(2) To replace broken tiles in bathroom 2. The registered manager should make available the results of the recent residents survey for residents and other interested parties. (Previous timescale of 30/3/06 is not fully met). To establish an annual development plan based on a systematic cycle of planningaction-review, reflecting aims and outcomes for service users. 5. OP38 13(3) 23(2)(4) To make the following improvements: To ensure full and continued compliance with the requirements made following a visit conducted by Environmental Services – Food hygiene on 16 November 2006. For example: - to replace perished and stained sealant around work surfaces in first floor kitchenette. - to ensure that light diffusers in the kitchen are kept clean and free from dead insects. 01/10/06 01/10/06 01/01/07 Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 30 To ensure full and continued compliance with the requirements made by the West Midlands Fire Safety officer following a visit on 9 December 2006 - to cease the use of door wedges. (For example to fit a suitable door closer to the small dining room on the ground floor). To ensure that all substances hazardous to health (COSHH) are held secure at all times and are not decanted into unlabelled containers. 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 YA9 Good Practice Recommendations To consider introducing a system for monitoring the number and balance of PRN tablets in MDS system which are not dispensed on a monthly basis. To consider displaying a weekly menu plan so that residents are provided with information about their forthcoming meals. To consider producing a pictorial menu plan to aid residents who have a mental illness (or are confused) to choose their meals and assist in menu planning. To continue to explore strategies for making mealtimes more congenial for residents for example refraining from using plastic tablecloths, plastic beakers, providing condiments on tables etc. Newbury Manor Nursing Home DS0000004864.V308922.R01.S.doc Version 5.2 Page 31 2. YA15 3. OP30 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.V308922.R01.S.doc Version 5.2 Page 32 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.V308922.R01.S.doc Version 5.2 Page 33 - 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!