Inspection on 27/02/06 for Newhey Manor, Residential Care Home

This inspection was carried out on 27th February 2006.

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

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

Other inspections for this house

Newhey Manor, Residential Care... 12/09/06

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 Unannounced Inspection 27th February 2006 09:00 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.V282397.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Newhey Manor, Residential Care Home DS0000043980.V282397.R01.S.doc Version 5.1 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.V282397.R01.S.doc Version 5.1 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. 19th September 2005 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. Newhey Manor, Residential Care Home DS0000043980.V282397.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 6 hours. The Inspector checked care plans and some other records, looked around parts of the building to make sure it was clean and checked what sort of activities the residents were doing each day to keep them from getting bored. The things the home had to put right from the last inspection were also looked at. In order to get information about the home, the owner/manager, joint owner, 6 residents, 4 staff and 2 relatives were spoken with. What the service does well: What has improved since the last inspection? The care plans now showed the steps staff were taking to make sure risks were reduced. More daily activities were taking place so that the residents had something to look forward to and to keep them occupied. Staff were not starting work at the home before the right checks had been made and this meant the residents were being cared for by staff that could be trusted. Newhey Manor, Residential Care Home DS0000043980.V282397.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Newhey Manor, Residential Care Home DS0000043980.V282397.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Newhey Manor, Residential Care Home DS0000043980.V282397.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 was assessed and met at the last inspection and standard 6 does not apply as the home does not offer intermediate care. EVIDENCE: Newhey Manor, Residential Care Home DS0000043980.V282397.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&9 The home’s care planning system ensures that residents’ assessed needs are being met. The administration of medicines was mostly satisfactory but did have some potential to place residents at risk. EVIDENCE: The care plans for 3 residents were checked, two for people who had been admitted on respite care with a view to making their placements permanent. The care plans were initially generated from the pre-admission assessment with a more detailed care plan being compiled as the staff identified other strengths or needs. The plans set out the action which staff needed to take to ensure that all aspects of the residents’ health, personal and social care needs are met. A daily routine sheet was also very informative and gave the reader a very clear idea about the person’s preferred rising/retiring times, whether they liked to stay in their rooms, likes and dislikes with regard to food and drinks and any other requests they had made. All the required risk assessments had been completed for all 3 residents i.e. falls, moving/handling, nutrition and skin (Waterlows). Where it was identified Newhey Manor, Residential Care Home DS0000043980.V282397.R01.S.doc Version 5.1 Page 10 there was high risk, a detailed action plan had been formulated showing how the risk was to be managed in order to lessen it. The care plans and risk assessments were being reviewed on a monthly basis and some reviews had been signed by the resident and/or relative. It was noted however, that the care plans had not all been agreed and signed by the residents and/or relatives and this should be addressed. The pharmacist inspector had carried out a full medication inspection on 3rd May 2005. On this visit, the requirements and recommendations made at that inspection were followed up. The manager said the home was going to change to the Boots monitored dosage system as they were dissatisfied with the service they were getting from their present supplier. Although the majority of shortfalls had been addressed there were still some areas that needed addressing. Handwritten MAR sheets were not signed or countersigned, the pharmacist had only undertaken one advisory visit on 5th April 2005, there were some missing signatures on the MAR sheets where staff had not signed after giving out medication and the home were still in the process of compiling a list of trained staff with their recorded initials. In addition, it was identified that some untrained staff were giving out medication under the supervision of trained staff. Only care staff who have successfully completed their medication training must be responsible for the administration of all medication. Newhey Manor, Residential Care Home DS0000043980.V282397.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 14 The provision of leisure activities had improved and they were appropriate to the service user group. Staff encouraged and enabled residents to make decisions about their preferred lifestyles insofar as they were willing and able to do so. EVIDENCE: The residents spoken to said they were satisfied with their chosen daily lifestyles and routines. Several people commented upon the improvement in provision of daily activities, which was a shortfall identified at the last inspection. The manager had now consulted with residents and their families about what to include on the programme, which was displayed in the home. The staff were also clear about who would be responsible for ensuring the activity was carried out, as each day a staff member was designated and their name recorded on the programme. An activities book, was in place in which staff recorded which residents had taken part in the activity and their feedback. Activities included bingo, baking, manicures/hand massages, reminiscence, armchair exercises and memory games. Such recordings also showed that more one to one activities had been done with individual residents e.g. going out for short walks, going to the shops, playing draughts, trip to Shaw market. “Active Minds” an outside Newhey Manor, Residential Care Home DS0000043980.V282397.R01.S.doc Version 5.1 Page 12 entertainer, also continued to visit the home fortnightly. One resident spoken with, who particularly enjoyed the weekly baking sessions, said she felt she was doing something worthwhile that she had enjoyed doing when she lived in her own home. She also said “it breaks the monotony”. Another new activity, which seemed to be enjoyed, was listening to stories. A care assistant would read short stories or extracts from the newspapers to those people who could no longer read, or indeed for anyone who wanted to listen. Resident feedback was very praiseworthy about the activities organised over the Christmas period for the residents and their families. Two residents identified they would like to go out more often on short trips during the better weather. 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 were able to make choices in many areas of their daily routines. One person enjoyed staying in his room all day, including having meals there. He said he valued his independence but that staff were there “at the press of the bell” and “responded quickly”. Other choices were for meals, drinks, rising/retiring times, what to wear and when to bath. Upon admittance, residents are encouraged to bring in personal possessions and small pieces of furniture in order they can personalise their bedrooms and this was seen during the inspection. Access to personal records is in accordance with the Data Protection Act. Newhey Manor, Residential Care Home DS0000043980.V282397.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The staffs’ knowledge and understanding of adult protection issues provides a safe environment to protect residents from abuse. EVIDENCE: The Rochdale MBC “Protection of Vulnerable Adult” (POVA) policy/procedures were held within the home. As part of the induction procedure, each new employee is given a shortened version of the document as well as a copy of the General Social Care Council “Codes of Practice”. Seven of the care assistants have undertaken the Rochdale MBC’s protection training although the manager had not. Whilst he was conversant with the procedures to be followed, it is recommended that he attend the next training course. Two staff interviewed were knowledgeable about what they would do if they suspected a resident was being abused. There have been no protection investigations made over the last 12 months. The files of two of the most recently recruited staff showed that appropriate Criminal Record Bureau and POVA checks had been done before they commenced working at the home. Newhey Manor, Residential Care Home DS0000043980.V282397.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The home was clean, free from unpleasant odours and satisfactory infection control practices were in place ensuring that residents were protected as far as possible. EVIDENCE: The home was clean and hygienic and feedback from both residents and relatives was very positive about how clean the home was kept. Policies/procedures were in place for the control of infection and in the main, staff were adhering to them. During the inspection, staff observed good hygienic practices by using disposable gloves, wearing blue disposable aprons for serving of food and white ones for assisting with personal care tasks. One care assistant who was interviewed, indicated that whilst she used disposable aprons when bathing residents, this would not always be the case if she were assisting them with toileting. The manager should ensure that all staff use disposable aprons when assisting with any personal care tasks. There was a plentiful supply of disposable gloves and liquid soap and paper towel holders were fitted throughout the home. Alcohol gel was also available on both the Newhey Manor, Residential Care Home DS0000043980.V282397.R01.S.doc Version 5.1 Page 15 ground and first floor corridors so that staff could use this until they were able to get to a wash hand basin. The staff were aware of the importance of washing their hands after attending to each resident and large “hand washing” signs were displayed in the staff toilet. Laundry facilities were inspected and found to be satisfactory. The home had 2 industrial washers and driers and both washers had sluice programmes. Soiled linen was carried to the laundry in bags and was washed separately. The majority of the staff, including the manager, had either completed infection control training or were in the process of doing so. Although standard 22 was not fully inspected, it was noted during the inspection that some wheelchairs were being used without the use of footplates. This practice can be dangerous and footplates must be fitted to all wheelchairs unless reasons for non-use are recorded in a residents care plan. Newhey Manor, Residential Care Home DS0000043980.V282397.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 30 Adequate staffing levels and appropriate training ensured the needs of the present resident group were being well met. EVIDENCE: Staffing levels were adequate to meet the needs of the current resident group. As the home is relatively small, there is no laundry assistant employed but care staff assist with laundry as and when needed. The night staff are usually responsible for the ironing of residents clothing. Some staff changes had taken place but several of the team had worked at the home for a considerable time. They felt that except for the occasional problems, they worked well together as a team. The feedback from the residents and relatives interviewed was extremely positive with regard to the staff team. They were said to “have a laugh with us”, “care well” and “be there when needed”. It was identified that two of the care staff employed, were not quite 18 years of age. These carers were spoken to during the inspection, and they demonstrated their maturity, together with awareness of exactly what they could do alone and what they needed supervision with. In addition, they had undertaken induction training as well as many other relevant health and safety courses. They were currently undertaking their NVQ level 2 training. The manager ensured they were never on the rota together in a caring capacity. In this instance, it is therefore acceptable they continue to work in a caring role, under direct supervision, until they are 18. However, the manager was advised that he should not employ any more under 18 care staff without first consulting with the Commission for Social Care Inspection. Newhey Manor, Residential Care Home DS0000043980.V282397.R01.S.doc Version 5.1 Page 17 From discussions with the staff, it was identified that a senior was not always identified, when the manager was not working i.e. evenings or nights. The rota must show who the person responsible is, so that in the case of an emergency, the staff are clear who will take the lead. Since the last inspection, more staff had completed their NVQ training. Of 18 staff employed, 6 had completed their NVQ level 2 and two had NVQ level 3 qualifications. In addition two nurses were employed as carers. Five carers were currently undertaking their NVQ Level 2 training. The home has therefore achieved over 50 of staff with a recognised qualification. Training records were in place, which showed the majority of the team had benefited from a range of training including fire, medication, infection control, first aid, food hygiene and moving/handling. Several had also benefited from training in dementia care, POVA, loss and bereavement and managing aggression training. The staff training matrix showed that with the exception of one night staff, all had done at least 3 days training, pro rata, over the past 12 months. The manager should ensure that all staff, irrespective of role or age, receive the appropriate training to do their jobs safely. Two of the staff interviewed confirmed they had completed their induction training. The home has now implemented the “Skills for Care” training for new carers without any previous training or experience. Those who are more experienced receive induction on the home’s policies/procedures, residents care programmes and aims/objectives of the home. Newhey Manor, Residential Care Home DS0000043980.V282397.R01.S.doc Version 5.1 Page 18 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 The manager provides strong leadership, guidance and support to staff to ensure residents receive a consistently good standard of care. Quality monitoring and reviewing processes were in place in order to seek the views of residents, staff and relatives about the service. EVIDENCE: The owner/manager is currently undertaking his MSC in Health & Social Care management. This is a two and a half year course that he is due to complete in January 2007. In addition he has undertaken mandatory training in health and safety, food hygiene, infection control and medication. The joint owner gives the owner/manager excellent support and provides valuable input into the home, especially with care plans and other related care practices. Feedback from the residents about the manager and joint provider was very positive. Staff interviewed also felt the manager gave them good support and Newhey Manor, Residential Care Home DS0000043980.V282397.R01.S.doc Version 5.1 Page 19 said that one to one supervision sessions were particularly valued. One care assistant said the manager was particularly supportive when she had personal problems and that the understanding shown had really made a difference. Another staff commented that he was “fair” and that “confidentiality was always upheld”. The manager is committed to providing a service that meets the needs of the residents living there. The home attained “The Investors in People” award in August 2004. An annual quality assurance survey is carried out involving residents, relatives/friends and staff. The evidence for the survey is obtained through the circulation of questionnaires. The feedback is then evaluated and published and a copy of the results displayed in the home. A copy is also sent to the Commission for Social Care Inspection (CSCI). Any constructive criticism is addressed as far as possible. The results of the last survey showed that residents and relatives felt more activities and stimulation could be provided within the home and action has been taken to address this shortfall. Other comments about staff taking their breaks together had also been effectively addressed. A residents/relatives meeting was held in January 2006. The minutes recorded that they had appreciated the improvements to the activities programme, especially over the Christmas period. Regular staff and management meetings are taking place as well as staff one to one meetings. Policies and procedures are regularly reviewed in the light of changing legislation and the home works co-operatively with the CSCI to implement any identified shortfalls. Newhey Manor, Residential Care Home DS0000043980.V282397.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X X Newhey Manor, Residential Care Home DS0000043980.V282397.R01.S.doc Version 5.1 Page 21 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. 1. 2. Standard OP9 OP9 Regulation 13 13 Requirement Handwritten entries on the MAR sheets must include full dosage instructions . Medication must only be administered by staff who are trained to do so and they must sign the MAR sheet as soon as medication has been dispensed. Wheelchair footplates must be fitted unless reasons for non-use are recorded on an individual’s care plan. A senior or responsible person must be designated on each shift when the manager is not working at the home. Timescale for action 31/03/06 31/03/06 3. OP22 13 31/03/06 4. OP27 18 31/03/06 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 OP7 Good Practice Recommendations Residents and/or their relatives should sign to say they have been consulted and agree their care plans. DS0000043980.V282397.R01.S.doc Version 5.1 Page 22 Newhey Manor, Residential Care Home 2. 3. 4. 5. 6. 7. OP9 OP9 OP9 OP12 OP26 OP27 Handwritten MAR entries should be signed, checked and countersigned. The pharmacist should make regular supervisory visits to the home. A list of trained carers and their usual initials should be maintained. More local trips out to places of interest should be included in the activity programme. All staff should be instructed to wear protective clothing when assisting residents with personal care tasks. Staff under the age of 18 years should not be employed without consulting with the CSCI. Newhey Manor, Residential Care Home DS0000043980.V282397.R01.S.doc Version 5.1 Page 23 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. Extracts may not be used or reproduced without the express permission of CSCI Newhey Manor, Residential Care Home DS0000043980.V282397.R01.S.doc Version 5.1 Page 24 - 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. 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