Inspection on 18/07/07 for North Bay House

This inspection was carried out on 18th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE North Bay House Borrow Road Oulton Broad Lowestoft Suffolk NR32 3PW Lead Inspector Deborah Kerr Key Unannounced Inspection 18th July 2007 09:45 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 North Bay House DS0000069810.V346458.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. North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service North Bay House Address Borrow Road Oulton Broad Lowestoft Suffolk NR32 3PW 01502 512489 01508 548116 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) Hellendoorn Healthcare Ltd Mrs Helena Hellendoorn Care Home 20 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (14) of places North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th September 2006 Brief Description of the Service: Mr and Mrs Hellendoorn purchased North Bay and became registered as the new proprietors with the Commission for Social Care Inspection (CSCI) in April 2007. The home is registered to provide care to a maximum of 20 older people, including up to 6 people with dementia, over the age of 65. North Bay is an attractively large house standing in its own grounds in a quiet road on the edge of the Oulton Broads. The gardens lead down to the waters edge, with trees, bushes and lawned areas offering a variety of features for people living in the home and their relatives to view. North Bay is approximately one mile from the nearest shops, facilities and Oulton Broad railway station. The home has fourteen single and three shared rooms. Fifteen of the bedrooms have en-suite washing and toilet facilities. Two bedrooms share a separate toilet and a total of ten bedrooms have an en-suite shower or bath facility. Bedrooms are on the ground and first floors; these are accessible by the staircase or a shaft lift. On the ground floor there are two lounge areas, one of which is a library and a reception hall with seating and a separate dining room. Each room is centrally heated. The lounges have views across the gardens to the waters of the Broads. There is a good-sized kitchen and laundry facilities to cater for the people living in the home. The terrace overlooking the gardens and the Broads is accessible for all people including those who use a wheelchair. The home has a statement of purpose and service user guide providing information about the home to prospective customers. Each person moving into the home is provided with a contract, which specifies their agreed fees and how much they are expected to pay on a weekly basis. Fees are calculated depending on the needs of the individual. These do not cover additional services for example, the hairdresser, chiropodist and personal items such as toiletries and daily newspapers. North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over seven hours on a weekday. This was a key inspection, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection, including information obtained from the Annual Quality Assurance Assessment (AQAA), issued by the Commission for Social Care Inspection (CSCI). Additionally a number of records were inspected, relating to people using the service, staff, training, the duty roster, medication, health and safety and a range of policies and procedures. A tour of the home was made and time was spent talking with the manager, deputy manager, two staff and eight people living in the home. What the service does well: What has improved since the last inspection? In the two months that Mr and Mrs Hellendoorn have owned the home, they have made a considerable number of improvements. A keypad entry system has been installed and fire safety locks fitted to doors, which now provide additional security safeguarding the people living in the home. A new cooker, and fridge have been purchased and installed. New windows have been fitted to parts of the house and the French doors in the library have been opened up and now lead out onto the patio creating easier access for wheelchair users. North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 6 Additional moving and handling equipment has been purchased and where people have been assessed as requiring nursing care, adjustable beds with pressure relieving equipment have been provided. To promote and respect people’s privacy, the new owners have installed a booster for the telephone system, which allows the phone to be used in different parts of the home, including people’s private accommodation. The home has been awarded a capital grant from Suffolk Association of Independent Care Providers for improving the care environment for older persons. This grant is being put towards the cost of replacing the carpets throughout the communal areas of the home. A new staffing structure has been implemented providing a diverse staff team with a range of skills, knowledge and experience to meet the needs of the people living in the home. What they could do better: Five requirements were made at the last inspection in September 2006. Three of these relating to care planning, record keeping and ascertaining the end of life needs of people living in the home have not been addressed by the previous owners and therefore remain areas for improvement. People’s care plans do not currently give sufficient information about the individuals needs, neither do they detail the actions staff need to take to ensure that all aspects of the person’s health, personal and social care needs are to be met. All records relating to people’s health needs must be regularly assessed, reviewed and updated to ensure any changes in their health are identified and action is taken to promote their well being. The end of life wishes of the people using the service need to be discussed, agreed and recorded in the person’s care plan with regards to terminal illness, death and dying. Although this is a sensitive subject this information needs to be ascertained and agreed with the individual and /or their relatives to ensure that in these circumstances the individual and their relatives will be treated with dignity and respect and in accordance with their wishes. To ensure people living in the home are safeguarded and protected from abuse, there must be robust recruitment policies and practice to obtain all of the appropriate checks prior to employing a person in the home. Staff must receive training appropriate to the work they perform, including adult protection, to ensure that there are suitably qualified persons working in the home at all times. A number of policies, procedures and other information about the home must be updated to reflect current practice and the new owners of North Bay. Consideration should also be given to producing information in a format suitable for the people using the home, in particular those with a visual or other sensory impairments. North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. North Bay House DS0000069810.V346458.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 North Bay House DS0000069810.V346458.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 6, People who use the service experience good quality outcomes in this area. People who may use this service have the information they need to make an informed choice about where they live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A colour brochure about the home is in the process of being printed. Once the brochure is ready the manager intends to introduce a welcome pack, including the existing statement of purpose, service user guide, fees and an ‘information only contract’. Consideration should be given to producing information in a format suitable for the people using the home, in particular those with a visual or other sensory impairments. At the previous inspection the home had admitted persons with dementia, which was outside their category of registration. The new owners have since been registered to provide care for up to six people with dementia. North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 10 Examination of three peoples files confirmed that prior to moving into the home two people had had a pre admission assessment completed. These contained relevant information about the individual’s health, social and personal care needs. There was no evidence on the third file that an assessment of need had been undertaken. It was noted that this person had moved into the home under the previous owners. People who had recently moved into the home spoke positively about their experience. The manger has also introduced post admission questionnaires, which people are asked to complete to reflect what it was like for them moving into residential care and to highlight any areas of concern to ensure that home can continue to meet their needs. Sample questionnaire’s completed, confirmed that people were satisfied with the admissions process. A comment made in one of the questionnaires stated “first class care and attention”. People’s files contained a written contract setting out the terms and conditions of residence, including a trial period and the method of payment. Files seen confirmed that the new providers had written to people using the service and /or their relative in April 2007, notifying them of the annual increase in fees. The new manager has demonstrated a commitment to raising standards at the home to meet the specific needs of the people using the service. They contacted Social Services raising issues about continuing to meet the specialist care needs of two people on their current level of funding. A social worker visited to review the current care needs in place for both people and arranged for a nursing needs assessment to be undertaken. (These issues are detailed in the health and personal care section of this report). The home does not provide intermediate care; subsequently this standard is not applicable. North Bay House DS0000069810.V346458.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11, People who use the service experience adequate quality outcomes in this area. Improvements need to be made to the care plans, health charts and risk assessments to ensure that the health and personal care people receive is based on their individual needs, this should include their wishes at the time of serious illness, death or dying. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Requirements from the previous inspection were made for a written plan as to how people’s needs in respect of health and welfare are to be met and to have assessments in place, which monitor people’s health and welfare. Examination of three peoples care plans confirmed these do not give sufficient information about the individuals needs, neither do they detail the actions staff need to take to ensure that all aspects of the person’s health, personal and social care needs are to be met. North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 12 Following a request to Social Services by the home’s manager to reassess the needs of two people currently living in the home. The Social Worker contacted the Commission for Social Care Inspection (CSCI) raising concerns regarding shortfalls in staff training, management of pressure care, continence, infection control and insufficient monitoring of peoples health care needs. These issues were followed up with the manager in writing and further during today’s inspection. Daily recording sheets are being completed which provide a description of the person’s well being and contain information about the care they receive. For an individual receiving palliative care the daily records show staff maintain their oral hygiene and bathe their eyes, however, entries do not reflect these are being done on a regular basis. One person’s plan states they require 2 liters of water to maintain hydration, there is no monitoring chart in place to reflect the amount and frequency they are offered fluids. Examination of the existing care plans confirmed where health charts and relevant assessments are in place, relating to moving and handling, pressure care, nutrition and continence management, these are not being reviewed and updated to reflect the individuals current and changing needs. The daily notes and entries in the senior’s diary confirmed that people are supported to access their General Practitioner (GP) and other local health services relevant to them. For people who are not well enough to leave the home arrangements are made for health professionals to visit them. Additional moving and handling equipment, including individual slings and slide sheets have been purchased. People who require these items for safe moving and handling have been issued with their own slings to minimise the spread of infection. Where people have been assessed as requiring nursing care the National Health Service (NHS) Suffolk Community Equipment Service has provided adjustable beds and pressure relieving equipment. The manager demonstrated the process of administering medication. The home uses the Monitored Dosage System (MDS). Medication Administration Record (MAR) charts are prefaced by a front sheet with the individual’s details and a photograph for identification purposes. Generally the process of receipt, administration and safekeeping of medication is well managed, however examination of the MAR charts identified a couple of gaps where medication, prescribed for the relief of constipation and eye drops had not been signed for. The manager stated that they are sourcing training from the pharmacist to provide refresher training to the senior staff that are responsible for administering the medication. The controlled drugs registered seen confirmed the home has currently one person prescribed a controlled medication, in the form of pain reliving, Fentanyl patches. A new secure cabinet for controlled drugs has been purchased, which has been secured to the wall within the medication cupboard. The stock of Fentanyl patches was checked against the register and was found to be accurate. North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 13 The homes medication policy and procedure needs to be updated, as they do not detail the actions staff should take to ensure medication is being received, stored and administered safely. A policy and procedure have been developed, agreed and signed by the GP and the pharmacist for holding and administering homely remedies. Staff were observed treating people living in the home with respect and dignity. The interactions between the individuals and staff are friendly and appropriate. Staff call people by their preferred name and respond sensitively to their individual’ needs and preferences. A previous requirement was made for information to be ascertained, agreed and recorded in each persons care plan regarding their end of life wishes. Examination of the care plans confirmed this has not happened. These issues need to be discussed to ensure that at the time of death or dying the individual is supported to manage degenerative and terminal illness through an established plan, which constantly monitors pain, distress and other symptoms. This will ensure that at the time of their death staff will treat them and their family in accordance with their wishes and spiritual beliefs with care, sensitivity and respect. North Bay House DS0000069810.V346458.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, People who use the service experience excellent quality outcomes in this area. People who use this service are able to make choices about their lifestyle, which enables them to live ordinary and meaningful lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussions with the people using the service confirmed that they are given the freedom and support where required to make decisions about how they spend their time, keeping to their own preferred routines. People were observed spending their time in their own rooms, lounge or library engaged in activities of their choice, listening to music, knitting and reading. One person living at the home has their own scooter, which enables them to go out and about in the community on their own to visit friends and shops. The first addition of a Newsletter was issued in May this year informing people living in the home and their relatives about the new owners and inviting them to a resident meeting to discuss future plans for the home. Following this meeting a ‘Friends of North Bay’ committee has been established to help raise funds to pay for future outings and entertainment. North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 15 A notice board has been put up in the entrance hall advertising activities available and names of the staff who are on duty. Activities advertised for the week commencing 16th July included a visit from the hairdresser, a ‘Pastimes’ reminiscence session, armchairs exercises, shopping trip to local well-known supermarket and a tramps supper, consisting of fish and chips. A residents and relatives meeting was scheduled for Saturday to discuss and arrange forthcoming activities, including preparations for a summer fete. Sunday, advertised a summer tea, followed by hymn singing and short meeting at the local Gospel Hall. Transport is provided by the homes mini bus. Leaflets advertising massage and beauty treatments were seen in the entrance hall. People can choose a variety of treatments at very reasonable prices, including, pedicure, manicures, anti ageing hand treatments and massage. The person who provides these treatments also visits the home to facilitate armchair exercise sessions. They have developed a programme using small weights and other exercise equipment to encourage people living in the home to take part in the physical activity to promote and maintain their mobility. People spoken with have found these sessions extremely beneficial to the overall well being. People are being supported to maintain links with the local community, a group of residents continue to take part in the ‘Inter Homes Quiz Competition’ which enables people to mix with people from neighbouring participating care homes. The quizmaster, a resident of North Bay, informed the inspector quiz nights are very popular. The home has an ‘open door’ policy, people spoken with confirmed they have regular contact with relatives and friends. People spoken with described the food as “very nice” and “the food is very good”. People can choose where they eat their meal, most prefer to use the dining room however, some people choose to eat in their room. A member of staff was observed supporting an elderly and frail individual to eat their meal in the quietness of the lounge, they were seen to provide support at a pace suitable for the individual to enjoy their meal. The menu for the day of the inspection provided people with a choice of liver and bacon or omelette, with seasonal vegetables, followed by a fresh strawberry flan. There is also a menu available with a range of options for people to choose if they require an alternative. People are requested to make their choices the day before to give the cook time to prepare and cook the meals. The lunchtime meal was observed, dining room tables were nicely laid with flowers and napkins. Food served looked appetising and was nicely presented. People were observed engaged in conversation with other people living in the home and the staff, making the mealtime a sociable occasion. Meals are all ‘home-cooked’ using mainly fresh, local produce. The food store seen confirmed that the home has a good range of quality food, with a selection of home baked cakes. These were being stored in accordance with food safety standards. North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18, People who use the service experience adequate quality outcomes in this area. People using this service have access to a robust and effective complaints procedure, however they cannot be assured that they will be protected from abuse until all staff have received up to date training for safeguarding adults using care services. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The policies and procedures for dealing with complaints and safeguarding the people living in the home were seen. Both of these documents need to be amended to reflect the new ownership of the home. The complaints procedure is displayed in the entrance hall, however consideration should be made to providing this information in alternative formats for people with visual and /or hearing impairments. The complaints log confirmed there have been no complaints made about the service in the last two years. The new owners have implemented a suggestion box located in the main reception, which they hope people using the service may feel more user friendly than making a formal complaint. People living in the home and staff spoken with confirmed they would go directly to the manager if they were unhappy about something. North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 17 Staff spoken with are aware of what constituted as abusive practice and would report an incident or an individual to the manager if they had any concerns about their conduct. However, the manager confirmed that staff training has fallen behind under the previous owners, including adult protection. The procedure for reporting allegations of abuse links to the Suffolk Vulnerable Adult Protection Committee (VAPC), directing people to Social Services, Customer First Team. The manager was advised that whilst the procedure remains the same the VAPC was disbanded in February this year and the Adult Safeguarding Board (ASB) created in its place. The policy and procedure relating to safeguarding adults will need to be amended to reflect this change. North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26, People who use the service experience good quality outcomes in this area. People can expect to live in a home that is decorated and presented to a high standard, which is comfortable and well maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the home was undertaken with the manager, the home is nicely decorated throughout providing a warm and homely atmosphere. There is a range of communal areas, including two lounges, one of which is a library and a reception hall with seating and a separate dining room. The lounges have a homely appeal with plants, papers and magazines and personal items arranged belonging to the people living there. Furnishings and lighting throughout the home are domestic in character and are suitable for their purpose. The lounges and a terrace overlook the gardens and broads. The terrace and gardens are accessible by all people living in the home and their relatives, including those who use a wheelchair. North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 19 People’s private rooms are nicely decorated and personalised to suit their individual tastes. All bedrooms are fitted with a call bell and people using the room are offered the option to have a key to their door. The manager informed the inspector that they have been awarded a capital grant from Suffolk Association of Independent Care Providers for improving the care environment. The money is being used to replace the carpets throughout the communal areas of the home. The manager identified a number of issues they are intending to address as part of a major refurbishment of the home. The refurbishment is planned to increase occupancy levels, but will also address some shortfalls in facilities currently provided. These include replacing the passenger lift, which is very small and difficult to accommodate wheelchair users. Three single bedrooms on the first floor do not meet the specified space required by the National Minimum Standard (NMS). The shower cubicles provided in the en-suites do not work and are not easily accessible by people accommodating the rooms. The previous owners used to live in an apartment on the second floor, comprising of kitchen, lounge, bathroom and three bedrooms. The manger has been in discussion with an architect to look at the possibilities of using this space to create additional accommodation and additional rooms on the ground floor under the terrace. The plans also include creating a treatment room, new laundry area and alterations to an out building previously used as storage to create a manager’s office, staff room and training facilities. The home currently has fourteen single and three shared rooms. Fifteen of the bedrooms have an en-suite hand washing basin and toilet facility. Two bedrooms share a separate toilet and a total of ten bedrooms have an en-suite facilities. Random testing of water temperatures reflected that the water supply is within the recommended 43 degrees centigrade, which minimises the risk of people living in the home scolding themselves when taking a bath. The home provides necessary equipment such as grab rails. These are positioned in toilets and bathrooms. A new bath chair has been purchased and installed in one of the bathrooms, other hoists and a stand aid are available to support people with their mobility and enable them to maintain their independence. The home was found to be clean and tidy with no unpleasant odours. Air fresheners are discreetly placed around the home, which give off a nice smell, and add to the ambience of the home. The laundry facilities seen were clean and tidy with appropriate equipment to launder clothing and bedding. The washing machine has a sluice facility for dealing with soiled linen. Appropriate hand-washing facilities of liquid soap and paper towels are situated in all bathrooms and toilets where staff may be required to provide assistance with personal care. North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30, People who use the service experience adequate quality outcomes in this area. A staff team, in sufficient numbers supports people who use this service, however the current recruitment arrangements and lapse in training does not ensure that people are in safe hands or are protected from abuse, neglect or harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels and training were examined using information taken from the completed AQAA and during the inspection. Historically the home does not have a large turnover of staff. The new owners have retained and recruited more staff. They have implemented a new staffing structure providing a team with a range of skills, knowledge and experience. The new structure includes the manager, who is a qualified nurse, a deputy manager, head of care and a care administrator, whom have completed National Vocational Qualifications at level 4. Two new care staff and two domestics have been recruited. The manger is looking to recruit more staff to meet the needs of the people living in the home by increasing the balance of younger carers and male staff, to ensure there is a mix of gender, enthusiasm and experience. Currently all staff in the home are female, there are five male residents currently living in the home. North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 21 The duty roster showed a senior and four staff cover the morning shits and a senior and three staff cover the afternoons, supported by the deputy and the manager. Two staff cover the night duty. The staff roster needs to be amended to make it clear who is in charge of the home in the absence of the manager and the designation of the staff, for example who the seniors and the deputy are. Examination of staff files identified that not all of the appropriate recruitment checks had been completed or were unavailable for inspection. Of the three files seen, one person had no evidence of a Criminal Records Bureau (CRB) check or Protection of Vulnerable Adults (POVA) check, the second had no POVA, and the third had no POVA and only one reference. Examination of application forms showed that the career history had not been fully completed by one new member of staff and therefore does not provide sufficient information of their past work experience and employment history. Two new staff files did not contain a copy of their terms and conditions of employment. The manager advised that there is a master copy of the terms and conditions on the staff notice board and that staff are issued with their own personal copy on completion their probationary period. An immediate requirement was left with the manager, to address the recruitment issues. One of the POVA checks and the missing reference were found and forwarded to the Commission for Social Care Inspection (CSCI). The manager contacted the previous owners, who informed them they had shredded the CRB and POVA documentation, but had kept a record in a logbook, which has since been located. However, the manager has written to the CSCI advising us that they as most of the staff have been in employment for over three years they intend for all staff to redo their CRB checks, which will be checked against the POVA register. Staff training has lapsed since the last inspection; the manager has identified this as a need in the AQQA to improve the service. They are currently developing a training programme to ensure staff have the competencies and qualities to meet the needs of the people living in the home. Training session are to be held throughout October to address these shortfalls, which will include fire safety, first aid and CPR, moving and handling and adult protection. Senior staff have enrolled on distance learning courses for equality and diversity and dementia awareness. The manager and the deputy are booked to attend a conference on the various aspects of dementia. The home employs twenty-two full and part time care staff. Figures in the AQAA reflect that fifteen staff have a recognised National Vocational Qualification (NVQ) level 2 or above, these figures confirm that the home has met the National Minimum Standard (NMS) target of 50 of care staff to hold a recognised qualification. North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 22 Staff spoken with confirmed that they had received an in house induction, which familiarised them with the layout and health and safety arrangements of the home. They felt supported by their colleagues and the management team. They were very clear about their roles and what is expected of them and were clearly able to describe the needs of the people living in the home, in particular the needs and level of support required for an individual with some behavioural issues. The manager is developing a package for new staff to be used as induction into the home and as a pathway to undertaking NVQ. They have purchased the training materials, which cover the six standards of the Skills for Care Induction, relating to the principles of care, the role of the worker, health and safety, effective communication, recognising and responding to abuse and develop as a worker. North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37, 38, People who use the service experience good quality outcomes in this area. The management of the home is based on openness and respect, and is run in the best interests of the people using the service, by a qualified and competent manger. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The new owners, Mr and Mrs Hellendoorn became the Registered Providers in April 2007. Mrs Hellendoorn has been approved as the Registered Manager. She is a Registered General Nurse, with a wide range of experience of working with older people and has a range of qualifications relevant to providing care services. She is currently undertaking the Btec Diploma in Business Management. North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 24 During the inspection, Mrs Hellendoorn demonstrated a good understanding of the needs of older people and the implications of providing a service for people with dementia. Although they have only been in post for 2 months they have already made improvement to the staffing levels, décor and security of the home. Discussion with people using the service and staff described the new owners as nice, welcoming and supportive. They spoke of feeling more included and consulted on the decisions made about the day-to-day and future running of the home. Handover meetings between shifts have been introduced, as well as regular staff and senior meetings. As part of their application to become the registered providers of North Bay, Mr and Mrs Hellendoorn submitted a business and financial plan setting out their plans for the home. These include refurbishment to increase occupancy levels, and to improve the layout of the home and increased staffing levels. Information provided in the AQAA states that the proprietors completed research of other care homes and feel that in comparison, North Bay are providing a service that is value for money. The manager has introduced post admission questionnaires, which people are asked to complete to reflect what it was like for them moving into North Bay. In addition to these the manager showed the inspector a questionnaire they have designed to distribute to all people living in the home and their relatives. They have identified in the AQAA the need to carry out an in depth quality assurance to evaluate the service they are providing and to analyse the results from which, they will develop an action plan to demonstrate where they need to make improvements. The manager has computerised all the accounts for the home. All fees are paid by standing order. The home does not act as appointee for any of the people living at the home. People are encouraged to manage their own money and financial affairs or they have the support of family or a power of attorney. Although the home does not manage people’s finances, for their convenience the manager does hold a small amount of personal cash for twelve people living in the home. This is held separately for each person and a record of transactions of all monies spent and received are logged. The records and balance for two people were checked and were found to be accurate. Concerns have previously been raised about the risk to people living in the home, where the garden’s lead down to the Oulton Broads. This is a particular concern for people that are elderly and mentally frail. There is a risk that people could wander and fall in to the water. The manager plans to erect wrought iron, decorative gates half way down the garden where there is a natural break with borders and shrubs and steps down into the lower garden. The gates will still allow views of the Broads but will provide additional security and minimise the risks of people falling and/or drowning. North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 25 Staff files confirmed that supervision has not taken place at regular intervals. Discussion with the manager and the deputy confirmed that a programme of supervision has been implemented. Staff spoken with confirmed that they felt supported and were able to go to the manager, or the deputy if they had any concerns or problems. Where supervision had been completed records confirmed that work issues and performance, training and further development needs had been discussed. Generally, people using the service are protected by the home’s record keeping. The accident book confirmed incidents and /or accidents are being reported and monitored. The AQAA confirms that the manager is reviewing the policies and procedures to ensure they are up to date and reflect good practice, however a number of these examined still had the former owners names as proprietors. Information obtained from the AQAA and seen during the inspection confirmed the home takes steps to safeguard the health, safety and welfare of people living in the home. Equipment and appliances are regularly checked and serviced; these include regular hot water checks and fire alarm testing. An entry in the diary confirmed that Portable Appliance Testing (PAT) of all equipment had been arranged for the following day. North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 26 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 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 27 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 All people using the service must have an up to date, detailed care plan, which includes the level and support required by staff. This will ensure that they receive the person centred support that meets their needs. This is a repeat requirement from the previous inspection 13/09/06 Health charts and risk assessments must be completed to identify the day-to-day interventions needed to promote their health and well-being. This must be reviewed and updated regularly to reflect peoples changing needs. This is a repeat requirement from the previous inspection 13/09/06 The end of life needs of people living in the home need to be discussed. This will ensure that in these circumstances the individual and their relatives will be treated with dignity and respect and in accordance with their wishes. DS0000069810.V346458.R01.S.doc Timescale for action 07/09/07 2. OP8 12 (1-3) 07/09/07 3. OP11 12 (3) 07/09/07 North Bay House Version 5.2 Page 28 4. OP18 13 (6) 5. OP29 19 (1) 2 Schedule 2 All staff employed in the home must attend training in the protection of vulnerable adults. This will safeguard people living in the home. The manager must ensure that all of the appropriate checks are undertaken prior to employing a person in the home. This will protect the people living in the home from the risk of suffering from abuse or being placed at risk of harm or abuse. 07/09/07 18/07/07 6. OP30 18 (1) (a) (c) People employed in the home 07/11/07 must receive training appropriate to the work they perform and to ensure that there are suitably qualified persons working in the home at all times. This will ensure the health, safety and welfare of people living in the home. 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 OP1 Good Practice Recommendations The service users guide and other information about the home should be available in a format suitable for the people with a visual and other sensory impairments. The home’s manager should conduct a monthly audit of medication to ensure medication is being administered safely and in compliance with the homes policies and procedures. The adult protection procedure needs to be amended to reflect the new Adult Safeguarding Board (ASB), implemented in February this year replacing the previous Suffolk Vulnerable Adult Protection Committee (VAPC). DS0000069810.V346458.R01.S.doc Version 5.2 Page 29 2. OP9 3. OP18 North Bay House 4. 5. OP36 OP37 Staff supervision sessions should be undertaken at least six times a year. The homes policies and procedures must be updated to reflect the new ownership of the home. North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 North Bay House DS0000069810.V346458.R01.S.doc Version 5.2 Page 31 - 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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