Inspection on 18/10/06 for Northbourne

This inspection was carried out on 18th October 2006.

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

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

Other inspections for this house

Northbourne 21/12/05

Northbourne 26/09/05

Northbourne 13/12/04

Northbourne 02/06/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Northbourne Durham Road Low Fell Gateshead Tyne & Wear NE9 5AR Lead Inspector Sheila Head Key Unannounced Inspection 18th October 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Northbourne DS0000007401.V309214.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. Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Northbourne Address Durham Road Low Fell Gateshead Tyne & Wear NE9 5AR 0191 482 5859 0191 482 4513 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) sharon.blackwell@anchor.org Anchor Trust Miss Alison Fryer Care Home 33 Category(ies) of Dementia - over 65 years of age (8), Mental registration, with number disorder, excluding learning disability or of places dementia (2), Mental Disorder, excluding learning disability or dementia - over 65 years of age (9), Old age, not falling within any other category (36), Physical disability over 65 years of age (13), Sensory impairment (2), Sensory Impairment over 65 years of age (2) Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st December 2005 Brief Description of the Service: Northbourne is a registered care home providing personal care for up to thirtythree people, most of who are elderly, and have either a history of mental health needs, a physical disability or sensory impairment. The home does not provide nursing care. The home has three floors. The lower ground floor accommodates utility services, which are the kitchen and laundry and the manager’s office. The ground and first floor accommodates communal areas, staff office and service users bedrooms (known as flats). All of the bedrooms benefit from en-suite facilities and there are a number of communal areas where service users can sit and relax. A passenger lift services the three floors and a call system is installed in all areas accessed by the service users. The Home is a purpose built home owned by Anchor Trust and is located on Durham Road in Low Fell Gateshead. There is no sign at the entrance off the main road therefore can be difficult to locate. It is close to shops, a medical centre, bus routes and other local amenities. There are garden areas and car parking facilities to the front of the building and is surrounded by trees and foliage. Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out over six hours by one inspector. The manager was present throughout. The Commission had received up to date information about services offered by the home and questionnaires that had been completed by service users. Some comments are included in this report. The inspector examined various documentation including care files, staff personnel and training records, maintenance checks and finance records. A tour of the building was carried out and lunch was shared with the residents. During the day the inspector spoke with residents, visitors and staff. Fees for this service are between £359 and £386 per person per week. What the service does well: What has improved since the last inspection? The home has been re decorated throughout all the corridors and has also been recarpeted. The chosen colours are calming and relaxing, plus with the addition of new lighting, the home appears much brighter and more pleasing. Residents commented, ‘I love the new colours as they are what I would have chosen at home’ and ‘the new carpets are simple but nice. It all works very well.’ Alterations in the basement area are now complete and the new medication room is operational. The administration office is larger and offers a more suitable working environment plus there is a room available for families to stay overnight if needed. Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 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. Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome is good. This judgement has been made from evidence gathered both during and before the visit to this service. Each resident has their needs assessed before moving into the home to ensure that the home can fully meet those needs. EVIDENCE: Three care files were examined. All contained in depth information that was gathered from the resident and their family before they were admitted to the home. This means that the resident could be confident that the home could look after them appropriately and meet all their assessed needs. This information is used as the basis for the residents’ care plan. Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 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): Quality in this outcome is good. This judgement has been made from evidence gathered both during and before the visit to this service. Each resident has a care plan that identifies their needs and gives clear instruction to staff so that they are looked after appropriately. The medication system is safe and usually meets the residents’ needs. Staff treat residents with kindness and respect ensuring their dignity and privacy are protected. EVIDENCE: Each resident has three files. One contains risk assessments that generate care plans and these are reviewed every month or when situations change. These evaluations were all up to date and necessary changes had been documented. Nutritional risk assessments were in place and all residents had a care plan that ensured their weight was checked monthly and in one case weekly as that had been raised as a concern. One resident who had visual impairment had a care plan suitable to their needs. For example a personal emergency evacuation plan had been formulated with their involvement to ensure the Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 Page 10 residents safety and to ensure they and the staff knew what to do if this was needed. All files contained the necessary information so that staff were clearly instructed how to look after and meet the needs of the residents. The second file contained past notes and information about the resident and was used as a filing system but past records were easily accessible if any of that information or detail was needed as reference. The third file contained the daily records, concerns that the resident raised that were not formal complaints but more personal concerns about their well being, hygiene recording if needed and present working records such as ABC charts or continence monitoring. These records were all up to date in the files examined so that residents can be confident that their daily needs are being met as they wish. Residents are involved in the care planning system and their views and those of families are well documented so that the resident is consulted, involved and aware of any decisions taken about their care. The home has a safe and effective policy in place for administration and storage of medicines. A pre dispensed monitored dosage system is used that minimises risk so that residents are protected. The records confirmed that the amount of medication received into the home, when it is given to residents and when it is returned to the pharmacy was accurately recorded and totals were correct. One error was noted in recording. One tablet remained in the blister pack but staff had signed as if the drug had been given. However the reason for the error in recording was written on the back of the sheet. The resident had left the home earlier than expected to attend an appointment. This does indicate that staff sign that medication is given before actually making sure the medicine is taken by the resident which is poor practice and can lead to residents not receiving their correct, prescribed medication, putting them at risk. The newly built medication room, trolleys and locked fridge were all clean and tidy. Attention must be paid by staff to ensure that the temperature of the fridge is documented daily as there were some gaps in the record. Staff were observed treating the residents with respect, observing their privacy and promoting their dignity. Staff knocked on doors before entering, always asked residents what they wanted and if they needed anything. If residents needed guiding or assistance this was always done in a discreet manner. The residents have access to a telephone ‘box’ so that they can receive phone calls in privacy. • I like being here • The staff are so helpful • This is my home now and I am pleases with the way its turned out as I was very worried about giving up my own home • They look after me well; there is nothing I can think of that I don’t have. These are some of the comments from residents. Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 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): Quality in the outcome is good. This judgement has been made from evidence gathered during and before the visit to this service. Residents are offered the opportunity of participating in a range of social activities. Links with families and friends are encouraged. The residents’ day is flexible and they are encouraged to make choices and take control of what they do. Residents are offered and receive varied, wholesome, nutritious and wellpresented meals. EVIDENCE: Talking with residents confirmed that they are able to take part in activities if they wish. Although there is not an employed activities organiser in the home the staff include this role in their daily workload. Through the ‘Friends of Northbourne’ group, that is made up of residents and families, activities, outings and entertainment are arranged. A programme is then developed that also gives staff time for one to one interaction so no one is left out. Residents are involved in making choices. For example residents were balloted about the use and position of the televisions in communal areas so everyone had their say and everyone agreed the television time. ‘We had two singalongs last week Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 Page 12 and this week we have two entertainment nights.’ Said one resident. The vicar visits monthly to give Holy Communion to those who want to receive it. Visitors came and went in the home all day and there are no restrictions on visiting times. Small kitchen areas in the communal lounges are available for visitors to make a hot drink for themselves and residents. Residents who wish to have a key to their ‘flat’ are supported and encouraged to so that they retain their independence as long as possible. The hairdresser was due to visit the home on the day of the inspection. Residents confirmed that although it was ‘hairdressing day’ that the hairdresser was on holiday and would not be visiting until the following week. The residents appeared well informed about what was happening in the home. The inspector shared lunch with the residents. There was a friendly, unhurried atmosphere with residents chatting to each other and with the staff. The tables were well presented with tablecloths, condiments, napkins and suitable cutlery. Glide/slide chairs made sitting at and moving from the table easier for those who were mobile. Residents are asked the night before what they would like to choose from the menu for the next day. Alternatives are always available and residents are able to change their minds if they wish. The choice for the day of inspection was steak and kidney pie with seasonal vegetables or egg curry followed by banana and custard or a choice of yoghurt. The food was plentiful, residents confirmed it was tasty and it was served hot. Residents had been asked if they wished to serve their own vegetables and had decided that they were happy if the staff served their meal. Breakfast is from 9a.m. and residents chose whatever they want as cereals and ‘hot’ food available. Teatime is around 5pm and again residents can chose from a traditional high tea such as burgers in buns, spaghetti on toast or a traditional, bread, sandwiches and cakes. One resident was celebrating a birthday and was looking forward to teatime, as they knew they would get a homemade birthday cake. The home uses fresh fruit and vegetables whenever possible and the residents are very happy with the homemade cakes. ‘I am very content. The food’s lovely and I never worry’ said one resident. Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 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): Quality in this outcome is good. This judgement has been made from evidence gathered both during and before the visit to this service. A robust complaints procedure is in place that gives clear directions to residents and visitors so that they know how to complain and who to. Staff are trained in adult protection procedures so that residents are protected from harm. EVIDENCE: The complaints procedure is available to residents and relatives and is displayed through the home so that they know who to complain to and how to make a complaint. The procedure is included in the service user guide that is in each ‘flat’ and complaints booklets are on display and available in the entrance. The manager keeps a register of any complaint and this was examined and found to be up to date. Residents are encouraged to tell of their concerns and staff are aware that concerns do not always have to take the ‘formal’ route, there is space for concerns documentation in the front of each individual care file. This philosophy promotes an open culture for staff and residents so that concerns can be talked about, sorted out very quickly and residents are satisfied. ‘The manager is very good. They sort anything out straight away’ ‘If the manager isn’t here I would just go to one of the staff they would sort it’ were some comments from residents and visitors. Staff training records demonstrate that all staff have attended Protection of Vulnerable Adults training, not only as part of their induction but also to Btec level. Talking to staff confirmed that they knew what to do if they suspected Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 Page 14 abuse or witnessed actual abuse. There is also local information and guidance available to staff. Residents can be confident that the staff group have the skills to protect them from actual or suspected abusive situations. Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is safe, clean, well looked after and comfortable for residents to live in. EVIDENCE: A tour of the premises was carried out and selections of ‘flats’ as well as communal areas were viewed. All ‘flats’ seen were personalised with items of residents’ own furniture and possessions. The home has just been tastefully redecorated in calming, peaceful colours along the corridors and they have also been recarpeted. All ‘flat’ doors have signage and a letterbox. ‘I really like my room’ said one resident, another said ‘I can stay in here or go to the lounge, I’m quite happy wherever I am.’ Repairs are carried out by outside contractors that respond very quickly. Specialist people contracted to the home also carry out routine maintenance and checks. Maintenance checks and results are clearly documented and are up to date. Heating and lighting through the home were comfortable and Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 Page 16 satisfactory. The laundry was clean and fit for purpose. The kitchen was also clean and the cook confirmed that she had plenty of equipment and always had plenty of stock so that residents could always be offered choice. No offensive odours were detected throughout the inspection. Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome is good. This judgement has been made from evidence gathered both during and before the visit to the service. The home is staffed to a level that ensures residents’ needs are met and staff are well trained to look after them. The recruitment policy ensures that residents are safeguarded from potential harm. EVIDENCE: The rota reflected the staff on duty during the day of inspection. Examination of past rotas confirm the home has enough staff every day and night to meet the needs of residents. The home operates a flexible staffing policy which means that staff are available for the ‘busier’ times in the day so that residents have their needs met. Also so that if the care dependency level rises, for example if someone needs extra care, staff are available. Staff files examined contained application forms, interview records, inductions, two references, Criminal Records Bureau check and contract. The files were clearly laid out and information was easily identified. Residents can be confident that this procedure safeguards them from harm. The home has developed a training matrix that identifies when individual staff training updates are needed and when training has been successfully completed. Each member of staff has their own personal development file that holds all relevant information about their training and holds copies of or original certificates. All staff have received training in health and safety, Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 Page 18 protection of vulnerable adults, dementia, moving and assisting and food hygiene. Training records are up to date. New staff must complete a comprehensive induction programme so that they know how to care for residents safely and effectively. Some staff are studying towards NVQ levels 2,3 and 4. Residents can be confident that the staff who care for them are well trained and updated when necessary so that they are safe and cared for appropriately. Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome is good. This judgement has been made from evidence gathered both during and before the visit to this service. The manager has the appropriate qualifications and experience to run the home competently. Systems are in place to monitor the quality of the service provided to the residents and to make sure that it is run in their best interests. Procedures ensure that the personal finances of residents are correctly administered and that their interests are safeguarded. Staff follow safe working practices so that residents’ welfare and safety are protected . Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 Page 20 EVIDENCE: The manager holds the Registered Managers Award and has continuous management experience to confidently run the home for the benefit of the residents. ‘The manager is always around if you have any questions’ said on resident. Discussions with the manager confirmed that they constantly update their knowledge and look at different ways to meet the needs of the clients. The overall good management of the home is reflects their suitability and competence. The home completes a self-assessment manual that covers all activities in the home such as care practices, health and safety, administration, kitchen and laundry activity and medicines. The manager or responsible member of staff carries these thorough audits out each month. The results of the audit identify any shortfalls in the service so that they can be correct and addressed quickly. The regional manage spot checks the audits when they visit the home to ensure compliance. The residents meet regularly through the ‘Friends of Northbourne’ group and are invited and encouraged to give their opinions and views. Residents’ monies are held securely and clear records are kept. The system remains unchanged from the last inspection. The records are both computerised and held on paper in the home. The manager audits the system and a second check is carried out by another person from outside the home to ensure all systems are being implemented correctly. Residents can be confident that their personal finances are safely managed and their interests are safeguarded. Staff were observed promoting safe working practices such as explaining to residents what they were going to do when assisting them to the toilet. Discussions with staff confirmed that they had been trained in fire safety, moving and assisting people and first aid. Training records relating to all aspects of health and safety were up to date. Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 4 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 Page 22 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 Standard OP9 Regulation 13(2) Requirement The Registered Person must ensure the safe administration of medicines and relevant documentation. Timescale for action 30/11/06 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 OP22 Good Practice Recommendations Door signage is of a suitable nature to enable residents to identify which is their flat. Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection South Shields Office Baltic House Port of Tyne South Shields Tyne & Wear NE34 9PT 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 Northbourne DS0000007401.V309214.R01.S.doc Version 5.2 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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