This inspection was carried out on 12th July 2005.
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.
CARE HOMES FOR OLDER PEOPLE
North Ferriby Nursing Home High Street North Ferriby East Yorkshire HU14 3JZ Lead Inspector
Jan Dulieu Unannounced 12 July 2005 9:30 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 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 Ferriby Nursing Home J53_J04_S943_North Ferriby Nursing Home_V233723_120705 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service North Ferriby Nursing Home Address High Street North Ferriby East Yorkshire HU14 3JZ 01482 631301 01482 631301 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Ian Holden Ms Patricia Owen Care Home 38 Category(ies) of Dementia - over 65 years of age (32), Old age registration, with number not falling within any other category (32), of places Physical disability (6), Physical disability over 65 yeasrs of age (32), Terminally ill over 65 years of age (32) North Ferriby Nursing Home J53_J04_S943_North Ferriby Nursing Home_V233723_120705 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3/11/04 Brief Description of the Service: North Ferriby is a nursing home for up to 38 service users. The home is in a converted house which has retained many of the features of a period property. There is a garden to the rear of the property. North Ferriby Nursing Home J53_J04_S943_North Ferriby Nursing Home_V233723_120705 stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection of the home was unannounced. The registered manager Mrs Pat Owen was present for the inspection. A tour of the home was conducted and both service users and relatives contributed their views about the care delivered in the home. Service user plans of care were also inspected. What the service does well: 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. North Ferriby Nursing Home J53_J04_S943_North Ferriby Nursing Home_V233723_120705 stage 4.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection North Ferriby Nursing Home J53_J04_S943_North Ferriby Nursing Home_V233723_120705 stage 4.doc Version 1.30 Page 7 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 standard(s) 1 and 5 Service users are supported to make an informed choice about coming to live in the home. EVIDENCE: The registered manager and responsible individual have developed the literature available for prospective service users coming into the home. Service users and their family are encouraged to visit the home prior to admission. North Ferriby Nursing Home J53_J04_S943_North Ferriby Nursing Home_V233723_120705 stage 4.doc Version 1.30 Page 8 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 standard(s) 7,8 and 10 Service users receive a high standard of nursing care. EVIDENCE: Service users are well cared for and both service users and relatives commented on the kindness and competence of the staff. They expressed particular confidence in the manager and said that ‘nothing was too much trouble’. The plans of care for service users are well developed and meet their nursing care needs. The plans of care inspected include entries on each shift by the nursing staff. North Ferriby Nursing Home J53_J04_S943_North Ferriby Nursing Home_V233723_120705 stage 4.doc Version 1.30 Page 9 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 standard(s) 12 and 13 Service users have access to activities and outings which they enjoy. EVIDENCE: The home has activities available and care staff also take service users on short outings. Some service users enjoy trips to the local public house opposite the home. Visitors are encouraged and supported to be involved in the home and they can access the manager if they wish to raise any concerns. Service users can maintain their own individual routines and staff respect their preferences and wishes. Service users said that they feel relaxed, comfortable and well cared for. North Ferriby Nursing Home J53_J04_S943_North Ferriby Nursing Home_V233723_120705 stage 4.doc Version 1.30 Page 10 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 standard(s) These standards were not inspected on this occasion. EVIDENCE: North Ferriby Nursing Home J53_J04_S943_North Ferriby Nursing Home_V233723_120705 stage 4.doc Version 1.30 Page 11 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 standard(s) 19,20,23 24 25 and26 Service users live in a clean and well maintained environment within the limits of a period conversion. EVIDENCE: The home is clean and odour free with the exception of one room which the registered manager is aware of. The smell of urine in this room must be addressed and overcome to ensure the dignity of service users is not compromised. The staircase carpet has been replaced and there are plans to re carpet the hallway. The first floor landing area has a raised metal rail to raise the height of the banister rail. A risk assessment has been conducted to address the considerable risk of service users who may be confused or have dementia to fall through the rail. Visitors children are also at risk and this must be made clear to all visitors. The rail has been in place for a number of years and has not caused any concern, however the responsible individual and registered manager must remain vigilant regarding the risk.
North Ferriby Nursing Home J53_J04_S943_North Ferriby Nursing Home_V233723_120705 stage 4.doc Version 1.30 Page 12 Service users rooms are attractively decorated and contain their personal items of furniture and items. North Ferriby Nursing Home J53_J04_S943_North Ferriby Nursing Home_V233723_120705 stage 4.doc Version 1.30 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and29 Service users benefit from being cared for by carefully recruited staff who have access to a variety of training opportunities. EVIDENCE: The personnel records contained evidence of two references being obtained and criminal records bureau checks are conducted. There is a staff rota available and the staffing levels meet the minimum standard required for the numbers of service users in the home at the time of inspection. There is a strong emphasis on training within the home and staff have access to a variety of training opportunities including NVQ training. North Ferriby Nursing Home J53_J04_S943_North Ferriby Nursing Home_V233723_120705 stage 4.doc Version 1.30 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32 and36 Service users live in a well managed home with caring staff. EVIDENCE: The registered manager inspires confidence in service users and staff and is effecting positive change in the home to ensure standards of care are raised and maintained . Records of staff supervision indicate that staff are being regularly supervised, training records indicate that staff are receiving both mandatory training and NVQ training. North Ferriby Nursing Home J53_J04_S943_North Ferriby Nursing Home_V233723_120705 stage 4.doc Version 1.30 Page 15 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x x x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x
COMPLAINTS AND PROTECTION 2 3 3 x 3 3 3 2 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 3 x x x 3 x x North Ferriby Nursing Home J53_J04_S943_North Ferriby Nursing Home_V233723_120705 stage 4.doc Version 1.30 Page 16 no Are there any outstanding requirements from the last inspection? 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. 3. 4. 5. 6. 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. Refer to Standard 19 Good Practice Recommendations The registered manager should continue to review the risk assessment regarding the first floor banister rail and remain vigilant about ensuring service users placed on this floor as well as visitors and their children. The registered manager should address the odour of urine in one room identified at the inspection. 2. 3. 4. 5. 26 North Ferriby Nursing Home J53_J04_S943_North Ferriby Nursing Home_V233723_120705 stage 4.doc Version 1.30 Page 17 Commission for Social Care Inspection Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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