Inspection on 12/09/06 for Newhey Manor, Residential Care Home

This inspection was carried out on 12th September 2006.

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

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

Other inspections for this house

Newhey Manor, Residential Care... 27/02/06

Newhey Manor, Residential Care... 19/09/05

Newhey Manor, Residential Care... 19/01/05

Newhey Manor, Residential Care... 20/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Newhey Manor, Residential Care Home Newhey Manor Huddersfield Road Newhey Rochdale Lancashire OL16 3RL Lead Inspector Jenny Andrew Key Unannounced Inspection 12th September 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 Newhey Manor, Residential Care Home DS0000043980.V305764.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. Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Newhey Manor, Residential Care Home Address Newhey Manor Huddersfield Road Newhey Rochdale Lancashire OL16 3RL 01706 291860 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) Lily Care Limited Dr Rida Youssef Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Within the maximum registered number (24) there can be up to:24 Older people (OP) The service should at all times employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. Date of last inspection Brief Description of the Service: Newhey Manor is a purpose built residential care home situated in Newhey, accommodating 24 service users over the age of 65 years. All the rooms are single, two having en-suite toilets. Permanent and respite stays are provided. Local shops are situated approximately half a mile away and the home is well served by public transport. Level access is provided to the main entrance. Car parking spaces are available to the front and side of the home. There are no private garden areas but service users may access the rear of the building, through patio doors, which open onto large playing fields. The home is well maintained both internally and externally. The weekly fees ranged from £323.01 - £379.00 as at September 2006. Additional charges were made for private chiropody, hairdressing and bingo. The provider made information about the service available upon request in the form of a Service User Guide and Statement of Purpose, which was given to new residents. A copy of the most recent Commission for Social Care (CSCI) inspection report was displayed in the entrance hall. Newhey Manor, Residential Care Home DS0000043980.V305764.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 over one full day with one Inspector. The inspector looked around parts of the building, checked the records kept on residents to make sure staff were looking after them properly (care plans) and other records the home needed to keep to help run its business. In order to obtain as much information as possible about how well the home looked after the residents, the owner/manager, deputy manager, 6 residents, chef, domestic, four relatives and the District Nurse were spoken with. In addition comment cards were sent out before the inspection to relatives, residents and professional visitors to the home. Of these 2 resident, 2 care manager and 1 G.P. questionnaires were returned. Other information, which had been received about the service, over the last few months, has also been used as evidence in the report. What the service does well: Residents felt they were well looked after by the staff and the following comments were made: “Staff have a good attitude”, “they look after me very well”, “staff will do what you ask them”, “get excellent care” and “staff seem to pull well together”. Throughout the inspection, the staff were seen to care for the residents in a kind, caring and considerate way. The manager made sure the home only cared for those people whose needs the staff could meet. The home kept good records of peoples needs and the care they gave to meet those meets. Staff contacted doctors, district nurses and other health carers when residents needed them. The residents spoken to were all really pleased with the meals they received with choices being offered at each mealtime. They commented; “excellent food”, “always a good choice of food”, “nothing too much trouble for the chef”, “the chef tries to please people when they’re ill” and “you certainly get enough food, sometimes too much”. Those people who needed special diets were well catered for and the staff had had training from a dietician so that they could make sure that the frail residents were getting the right food so they would not lose weight. The home was careful about whom they offered a job to and made sure they checked people out before offering them a job. The building was clean, hygienic and kept in good order throughout. Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 6 The manager met regularly with the staff both in team and one to one meetings so that the staff were clear about what they were doing well and what needed to be improved upon. The manager was good at checking out the quality of care given. To do this, he asked residents, relatives/visitors and staff about their opinions and took steps to put what they said into practice. What has improved since the last inspection? 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. Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 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 Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 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): 1&3 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The admission process was good with relevant information being given to residents before they moved in and an assessment taking place to ensure the home could meet their identified needs. EVIDENCE: The statement of purpose and service user guide had been updated and were displayed within the home. Copies of these documents were given to each new resident in accordance with the home’s admission policy/procedure. Three files were inspected and each contained an assessment, done by the manager before the resident moved into the home. Where care managers were involved in the admission, they provided a detailed needs assessment also. Feedback from residents and relatives indicated they were appropriately involved in the assessment process and considered the home was able to meet their needs. Information from the assessment documents had, where relevant, been included in the residents care plans. Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 9 As the home had several mentally frail residents living there, the manager and 5 staff had undertaken dementia care training, in order to understand more fully how to meet these peoples needs. Also advice had been sought from a physiotherapist, about the medical condition of one resident which had resulted in staff assisting with exercises, which had been recorded in the person’s care plan. Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 10 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 & 10 Quality in this outcome area is excellent. This judgment has been made using available evidence including a visit to this service. Residents’ health and personal care needs were being well met and personal care and support was offered in such a way as to promote and protect residents’ privacy, dignity and independence. EVIDENCE: Three individual plans of care were inspected, two for residents who had been recently admitted. All 3 were detailed and had the information that staff needed in order to provide the right care and support to each person. The care plans were drawn up in consultation with the resident and/or relative and two of the plans had been signed. The other plan was awaiting the relative visiting so they could read through it and sign on behalf of the resident. Care plans were reviewed and updated on a monthly basis. One relative had written a care plan for the home to use and they had included the information provided in their own plan of care. In addition, records relating to bathing, hair washing, weight and bed changes were in place and all were up to date. Residents spoken to all said they Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 11 received sufficient baths and at the time of day they preferred to take their bath. One resident had recently requested her bath time be changed from after tea to before breakfast and this was now happening. Another person said “you can have a bath when you want, the staff are always anxious to bath someone”. The good practice of staff monitoring and recording the condition of residents’ skin on a monthly basis was also noted. The manager checked these records in order to ensure they were kept updated and appropriate action was being taken to address any concerns that had been identified. Residents had regular access to chiropodists, opticians and district nurses but the home was experiencing problems in getting home visits from dentists. Referrals through G.P’s were made where staff identified problems in other areas. Visits by health care professionals were recorded on the individual resident’s file. One resident said “staff send for your own doctor when you’re feeling poorly” and another resident, who had recently received a doctor’s visit said he was getting regular pain relief. The falls co-ordinator was also consulted, whenever the staff felt it was necessary. When health care professionals visited, they were always escorted by a member of staff, who recorded the outcome of the visit in a book, kept for that purpose. This information was then transferred to the individual’s care plan. The visiting district nurse commented that staff co-operated fully with any instructions given and that the residents always looked well cared for. She also commented upon the pleasant attitude of the staff. She confirmed that whenever she asked for pressure relief aids, they were always provided. A returned questionnaire from one G.P. did however state that the staff did not always demonstrate a clear understanding of the needs of the patient and the manager said he would look into this. The manager and 11 of the staff, including the Chef, had recently done training with the dietician on how to use the MUST tool (Malnutrition Universal Screening Tool). This was an assessment document that alerted staff to take action if a resident was assessed as being at risk of malnutrition. Following the training, each resident had been assessed, resulting in 4 people being assessed at high risk. The manager had taken appropriate action by writing to individual G.P.’s advising them of the assessment outcomes. This had resulted in a visit from the dietician and her recommendations had been implemented. Good results were already evident with two people moving from high to medium risk as a result of good weight increases. All 3 files contained assessments relating to moving/handling, Waterlows (skin) and falls. Where other risks had been identified, assessments were in place for example self-medication and beds being fitted with safety sides. Risk assessments were reviewed on a regular basis. Where it was identified there was high risk, a detailed action plan had been formulated showing how the risk was to be managed in order to lessen it. Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 12 All residents spoken with felt they were being well cared for by the staff team. Relative feedback also indicated they were satisfied with the overall care provided by the home. Satisfactory arrangements were in place in relation to the administration, dispensing and storage of medication including controlled drugs. Following 2 requirements made at the last inspection in relation to medication, the manager had been monitoring staff practice and this was evidenced from reading the staff meeting minutes. The home had changed to the Boots monitored dosage system in April 2006, and the manager and staff felt this was a more efficient system. From observing the lunch-time medication round, the carer was seen to administer the medication efficiently, signing the Medication Administration Records (MAR) only after making sure each resident had swallowed their tablets. The medication policy included self-medication but it was unusual for residents to hold anything other than inhalers or creams. Where they were, risk assessments had been completed. All staff, responsible for giving out medication, had received appropriate training. The aims and objectives of the home reinforced the importance of treating residents with respect and dignity. Residents interviewed were all complimentary about how staff assisted them with personal care tasks and felt their privacy and dignity was respected at all times. This was also observed during the inspection. Residents were asked quietly if they needed the toilet, they were taken without having to wait, toilet doors were closed and staff knocked on bedroom doors before entering. Relatives confirmed they were satisfied with the staff’s manner and attitude towards the people they visited. The care assistants interviewed were able to give good examples of how they promoted privacy and dignity in their daily care routines. These included using the right approach and giving gentle encouragement, explaining to people what you are going to do and why so they didn’t become angry and frustrated, encouraging people to be as independent as possible especially when bathing and knocking on doors before entering. Two residents said when staff were busy, it was sometimes difficult for them to attract attention in the lounge as the call bell was fitted some way from their chairs. Discussion with the manager took place and he was to speak to the residents and agree what could be done to address this problem. It was acknowledged there were times when staff were assisting residents with personal care tasks, when staff presence was not always possible in the lounge. One idea was for a hand bell to be placed within reach of these residents. Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 13 All assistance with personal care was given in the privacy of service users bedrooms or bathroom. Service users were also able to meet visiting professionals and family/friends within the privacy of their own rooms. The induction training programme, which was now done by all new staff, included how to treat residents with respect and dignity. Residents were also encouraged to remain as independent as possible and this was observed during the inspection. Residents who were becoming less mobile were being encouraged to continue to walk, with the aid of their zimmer frames or walking sticks. The home was adequately equipped with necessary aids and adaptations, which promoted people’s independence. At mealtimes, whilst assistance was given where needed, residents were prompted by staff to continue to eat their meals themselves. Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 14 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 & 15 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Residents were able to follow their chosen lifestyles both in and outside of the home and varied and nutritious meals for the residents were provided. EVIDENCE: The improvements identified at the last inspection, in relation to the provision of activities, had been maintained. From speaking to residents and entries made in the activities book, it was evident that the needs of both individuals and groups were being addressed with regular one to one local outings to shops and the local park being organised throughout the summer. One person had been supported to visit the library. In addition 3 residents had been to the cinema and 6 had enjoyed a shopping trip to Rochdale. In-house activities consisted of weekly bingo, nail care, fortnightly visits by an outside entertainer “Active Minds” and random activities such as arts/crafts, quizzes, reminiscence and memory games. Two residents said they had particularly enjoyed watching the Whitsunday parade and the local carnival. The manager had bought a DVD player together with films such as Laurel and Hardy, which the residents were said to have enjoyed. One resident said she liked to go out for short walks around the home unaccompanied and that this was not a problem. Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 15 Previously baking sessions had been introduced, but since the member of staff who organised the sessions had left, this activity had ceased. Whilst two residents said they did not wish to continue with the baking, the manager should check out with the other residents whether or not they would like this activity to be re-introduced. Two residents had recently enjoyed watching one of the care assistant’s wedding video, which she had brought in to the home. In August a barbeque had been arranged for residents and their relatives and although it had rained, the residents said they had enjoyed the occasion. Several residents said they preferred not to join in activities and that staff respected their wishes. Good provision was made for residents to continue to follow their chosen religions, with regular attendance at the home by representatives from both Church of England and Roman Catholic faiths. Residents and relatives spoken to confirmed that visitors were made welcome in the home and were offered refreshments. Visiting relatives took some residents out on a regular basis and they looked forward to this. This helped to maintain community contacts for them. In addition staff would also take people out on an individual basis to the local shops and this was observed on the day of inspection. Residents were able to make choices in many areas of their daily routines but this did depend on their mental frailty. Those spoken with said they could choose when to get up, go to bed, what clothes to wear, what food to eat and whether to take part in activities. The residents were extremely praiseworthy about how the chef took the time and trouble to make sure they were served with the food they enjoyed. Likes/dislikes were established upon admission and included in the care plan. The Chef had worked at Newhey Manor for many years and knew each person’s likes/dislikes and portion sizes. Menus were inspected and seen to provide a balanced, nutritious and varied diet over a 4 week period. Grapefruit, cereal or something cooked was offered at breakfast with between 2 and 5 residents opting for the hot meal. Two hot choices were served at lunchtime and a choice of sandwiches or a hot snack at tea. Desserts were served at both meals. In addition residents enjoyed supper at around 7.00 pm when sandwiches, toast, cakes or biscuits would be offered with a second supper round offered at 9.00 p.m. Residents said that if they felt ill or didn’t like what was on the menu, they would be offered something else. All the residents spoken with were complimentary about the food and this has been the case at previous inspections. Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 16 On the day of the inspection, the lunch choices were, poached salmon in cream and butter sauce, sautéed potatoes, cauliflower and carrots or braised lamb chops, mashed potatoes and vegetables. The dessert was coconut tart and custard or icecream. The tea choice was bubble and squeak, sausage egg and tomato or sandwiches followed by angel delight and shortbread or peaches and carnation cream. The inspector sampled the lunch meal and it was excellent. One resident commented on how much she had enjoyed the sauce served with the salmon. One area, identified by the residents as to how meals could be further improved, was to make teatime a little later. At present lunch was served at 12.00 and tea at 4.00 p.m. Residents’ felt 4.30 would be better as they would feel hungrier by then. This was passed on to the deputy during the inspection and before the inspection had ended, she had taken a vote from the residents about this change of mealtime. As a result, it was agreed that the manager would speak to the chef and arrange tea for 4.30 p.m. This prompt action showed how feedback from the residents was valued, with swift action being taken to try and implement their wishes. The individual dietary needs of residents were being met and dietary and fluid charts were completed as and when needed. As previously stated all residents had been assessed using the Malnutrition Universal Screening Tool (MUST) and good results had already been achieved as a result of residents receiving additional nutritional supplements. Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. An effective complaints system was in place which residents were familiar with and staff training and good recruitment practices ensured that residents were protected from abuse. EVIDENCE: A complaints procedure was in place which was included in the service user guide and statement of purpose. It was also displayed within the home. A complaints log book was in place but no complaints had been recorded over the last 12 months. Neither had the Commission for Social Care Inspection had cause to investigate any complaints. There was a comments book kept and many thank you cards were seen to have been received. In addition a comment box was in the entrance in which relatives or residents could post comments or suggestions. The residents spoken with all felt they could speak to the manager or any of the staff about problems and that they would be listened to. A procedure for responding to allegations of abuse was available as was the Rochdale Inter-Agency Protection of Vulnerable Adults (POVA) procedure. No protection investigations had taken place over the last year. Since the last inspection, the manager and 5 of the staff had attended the Rochdale MBC POVA training course. In addition all but one night staff had either completed NVQ level 2 or were in the process of doing so. This training included a unit on elderly abuse. Staff files showed that Criminal Record Bureau and POVA first Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 18 checks had been done before any new staff started work so as to ensure that the staff were suitable to work with vulnerable people. Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 19 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 & 26 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home was clean, safe and well maintained providing a comfortable and homely environment for the residents. EVIDENCE: The home was well maintained and when bedrooms became vacant, they were re-decorated before a new resident was admitted. Since the last inspection, a shower cubicle had been fitted in the first floor bathroom which 2 residents regularly used. Also the majority of the dining room chairs had been replaced and a DVD player had been bought. The residents spoken with were all satisfied with their bedrooms and said the home was kept clean. One resident said, “my room is lovely” and another said, “my room is kept spotlessly clean”; one person said “I don’t think you could live anywhere better”. Relatives were also complimentary about the Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 20 cleanliness within the home and said that the home did not have any malodours and a walk around the building supported this view. The report of an Environment Health inspection on 22 February 2006 was seen and it commented upon the good records and documentation produced by the home. No requirements were made. Hot water temperatures were randomly checked in bathrooms and found to be satisfactory. Window restrainers were fitted to all first floor bedroom windows. Level access was provided and a passenger lift was provided to the first floor. Residents said they could get around the home fairly easily and appropriate aids and adaptations were fitted in bathrooms, toilets and corridors so that residents could remain as independent as possible. Everyone spoken with thought the home was a safe place to live and work in. It was however, identified that wheelchairs were being stored in one of the bathrooms, which could have been a safety hazard for residents. They were however, removed during the inspection. An infection control policy was in place and the manager and 10 staff had attended an infection control course. The staff interviewed described safe infection control practice. Disposable gloves and coloured aprons were provided for staff use and liquid soap and paper towels were supplied in all bathrooms and toilets. In addition alcohol based hand wash dispensers were provided on both levels of the home which staff regularly used. It was observed at lunchtime that staff wore white disposable aprons, and this colour apron was also used when assisting residents to bath. Blue aprons were used for toileting residents. It is strongly recommended that blue aprons be used for serving food and white aprons be used when assisting residents with personal care tasks. This practice would then enable the manager to monitor that staff had changed their aprons before dealing with food. In one of the bathrooms, two tablets of soap were seen. The manager said the staff must have left it when bathing 2 residents and it was removed during the inspection. The laundry was sited away from the food preparation area and was clean and orderly. Sufficient and suitable equipment was provided and the washers were equipped with sluicing facilities. One relative said, “my mother always has nicely ironed clothes on when I visit”. Another relative said, “clothes are changed when spills are made”. Residents said if laundry was misplaced that staff would look for it and they would usually get it returned. Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 21 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 & 30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Sufficient numbers of staff, with an appropriate skill mix were provided who did not start work until all references and checks had been undertaken. EVIDENCE: Inspection of rotas showed that staffing levels were adequate to meet the needs of the current resident group. Following a requirement made at the last inspection, 2 team leader posts had been created in order there was a designated person in charge on each shift. Since the last inspection there had been some changes in the staff team. Whilst several of the team had worked at the home for some years, others were relatively new. There were 2 staff vacancies, which were being advertised. In order to provide sufficient cover, the existing staff were working additional hours. The rota for the week of the inspection showed that 2 staff were each working two double shifts i.e. 8.00 – 15.00 and 15.00 – 22.00. Clearly 14 hour shifts are excessive and staff cannot be expected to perform effectively when working such long hours. The manager should ensure that additional staff are recruited so this practice can be discontinued. Since the last inspection, an additional domestic had been employed for 3 days per week, including one day at weekend. The domestic spoken to during the inspection, said this had made a big difference as between them, they could ensure that all areas of the home were thoroughly cleaned each week. Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 22 Whilst 4 male residents lived at Newhey, there was only one male night care worker. The male residents spoken with said they had no objection to female workers assisting them with their personal care. The manager said one male resident had initially been slightly embarrassed, but that the care staff had built up good relationships with him and it was no longer a problem. The staff team was all white British, except for the manager, but this reflected the current service user group. Feedback from the residents was very positive about the staff team and manager. From observations made during the report, it was evident that good relationships had been made between staff and residents and staff were seen to be respectful towards residents. Staff feedback about team working was generally good although two people felt that communication between staff could be improved. Both the owners were committed to offering training opportunities to the staff. Of the 13 staff employed 8 had successfully completed NVQ level 2 training or above and 4 had almost completed NVQ level 2 training, resulting in the home having attained 61 trained staff. Three of the staff had recently registered to do their NVQ level 3 training and one carer had already achieved this qualification. The manager was also being more selective when recruiting staff and had recently recruited 2 carers with NVQ qualifications. Inspection of records showed that safe recruitment and selection practices were followed in line with the home’s procedure. These included receipt of 2 satisfactory references, Protection of Vulnerable Adults (POVA) and Criminal Record Bureau (CRB) checks before starting work. Staff were also given copies of the General Social Care Council “Codes of Practice” upon appointment. One of the newly recruited care assistants confirmed she had not started work until all her checks had been received by the home. This was also confirmed from checking two files for the most recently recruited staff. Skills for Care induction training was in place for new staff. It was however, identified that the training was sometimes taking longer than the recommended 12 weeks. From checking two files, it was noted that where staff had successfully completed NVQ level 2 training, this was not being cross referenced within the training records and staff were completing all sections of the training rather than the sections specifically relating to policies/procedures, aims/objectives and care practices within the care home. The manager said he would address this in future induction training. From checking the staff training matrix, it was noted that staff had received all mandatory training and attended refresher training as and when needed. Over the last 12 months 10 staff had done falls awareness training, 12 nutritional training from the dietician, 5 attended first aid, 4 done moving/handling, 3 infection control, 2 food hygiene and 3 dementia care. This meant that all Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 23 training was up to date for the existing staff and training certificates were seen in the files checked. Newhey Manor, Residential Care Home DS0000043980.V305764.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, 36 & 38 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The manager provided effective leadership and support to staff ensuring that residents received a consistently good standard of care. EVIDENCE: The provider/manager was currently undertaking his MSC in Health and Social Care Management, which he expected to complete in June 2007. Being on this course meant that he was up to date with current care practices and research. Since the last inspection, his training record showed that he had, over the last 12 months, undertaken training in first aid, dementia, infection control, medication, falls awareness and nutrition. It was evident from records seen and from speaking to staff that he was extremely vigilant about monitoring care practices within the home and he Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 25 regularly made spot checks of medication and care plans. Any weaknesses identified from any source were immediately addressed to ensure staff consistently adhered to the home’s policies and procedures. Feedback from the residents, relatives and staff about the manager was very positive. He was said to be fair, approachable and offered the staff good support. The staff interviewed all said they received regular one to one sessions, which they valued and supervision records confirmed that these were usually done monthly. All felt he fostered an atmosphere of openness and respect and one relative said she felt he valued her opinions. A number of quality assurance measures were in place and the home had achieved the Investors in People Award in 2004. This was due for renewal in August 2007. An annual quality assurance survey was carried out involving residents, relatives/friends and staff. The evidence for the survey was obtained through the circulation of questionnaires and the manager was awaiting the return of more questionnaires before collating and evaluating them in readiness for the 2006 report. Upon completion, the results were published, displayed within the home and included in the service user guide. This was evidenced for the previous year. Any constructive criticism was addressed as far as possible. One relative questionnaire had suggested that sun parasols be provided and these were seen outside the home with the outdoor furniture. The Commission for Social Care Inspection (CSCI) were also sent a copy report. Only one resident/relative meeting had taken place this year and this had been held in January 2006. The minutes recorded that they had appreciated the improvements to the activities programme, especially over the Christmas period. In order to try and involve the residents as much as possible in the running of the home, more regular meetings should take place. Staff and management meetings were taking place regularly as well as staff one to one meetings. Minutes of such meetings were seen. Policies and procedures were regularly reviewed in the light of changing legislation and the home worked co-operatively with the CSCI to implement any identified shortfalls. Any requirements made in reports were always addressed within the given timescales. The majority of the residents living at Newhey Manor, relied upon their relatives to handle their financial affairs. The home were only managing money for one person and appropriate receipts were seen to have been signed by the resident upon receipt of their personal allowance money. Some relatives left money at the home for staff to give to individual residents as they needed it and again, receipts were in place where staff had purchased items on their behalf. Hairdressing accounts were also in place. Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 26 The pre-inspection questionnaire recorded that all required health and safety policies and procedures were in place. In addition, the manager was vigilant in ensuring that staff received their health and safety training with refresher courses being arranged as needed. The pre-inspection questionnaire also showed that maintenance checks were up to date except for small electrical appliances. Random record sampling was undertaken of the public liability certificate, the Environmental Health Officer’s last report, lifts/mobile hoists and small electrical appliance checks. The small electrical appliances had last been tested in 2004. The Inspector was of the view these should be tested biannually and the manager was to contact the Health and Safety Executive to check out the frequency. As the manager was a chartered engineer and member of the Institute of Electrical Engineers, he was qualified to undertake the testing of appliances himself and advice given by Health and Safety should be implemented. As a result of a requirement being made at the last inspection, for wheelchairs to be fitted with footplates, the deputy manager had labelled all footplates, so that the correct ones would be easily identified if they had been removed for storage purposes. Those in use were observed to have footplates fitted. Newhey Manor, Residential Care Home DS0000043980.V305764.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 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 3 X 3 X 3 3 X 3 Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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. 3. 4. 5. Refer to Standard OP26 OP27 OP30 OP33 OP38 Good Practice Recommendations When serving or preparing food, disposable blue aprons should be used by care staff to distinguish from the white aprons used for personal care tasks. Staff should not work excessive hours and more staff should be employed to ensure this is not necessary. Skills for Care training should be completed within 12 weeks and cross-referencing should be done where staff have completed NVQ or other relevant training. More regular resident meetings should take place. The manager should consult with the Health and Safety Executive to determine the frequency of small electrical appliance checks and implement as advised. Newhey Manor, Residential Care Home DS0000043980.V305764.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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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