Inspection on 21/12/05 for Northbourne

This inspection was carried out on 21st December 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Northbourne 18/10/06

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 Unannounced Inspection 11:00a 5 and 21st December 2005 th 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.V270441.R01.S.doc Version 5.0 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.V270441.R01.S.doc Version 5.0 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) 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.V270441.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th September 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.V270441.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the annual inspection programme and lasted seven hours on the first day then the inspector re visited the Home on the 21st December to look at more documentation. There were 31 residents in the home with enough numbers of staff to look after them. The Registered Manager was on duty throughout the inspection. The inspector spoke with most residents, however, five residents, four members of staff and three visitors were spoken with in depth during the day. A sample of were looked at including two care plans, two staff files and four residents’ personal files. A tour of the premises took place and lunch was shared with the residents. What the service does well: The home has a group of staff that has worked there for a long time that know the residents well and meet their needs. Staff are pleasant and caring and one resident said ‘they are never down in the dumps, always cheery’. Staff and residents relationships are very friendly and respectful. Visitors are encouraged to make use of the small kitchens making drinks for themselves and residents. Several visitors said that they feel ‘comfortable’ when visiting and that Northbourne is ‘a grand place’. They said they feel at home and always feel welcome. Meals are varied, there is a wide choice and they are well presented. Residents can always have something else if they don’t want what is on the menu. One resident said ‘it is better than home’ another ‘we can have anything we like.’ During the inspection there was a fire drill that was handled well by staff. All staff knew what to do and where to go. Northbourne DS0000007401.V270441.R01.S.doc Version 5.0 Page 6 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. Northbourne DS0000007401.V270441.R01.S.doc Version 5.0 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.V270441.R01.S.doc Version 5.0 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): 2 and 6 People who use the service all receive a clear contract and statement of terms and conditions that explains the service they receive. EVIDENCE: Residents have a written contract that was signed that also had information and details should the resident wish to leave the home. Also there was information for the resident to help them understand the arrangements for living in the home. The home does not offer intermediate care. Northbourne DS0000007401.V270441.R01.S.doc Version 5.0 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): 9,10 Medication practices ensure that the needs of the residents are met. Clear systems are in place. Staff show respect to the residents and are polite at all times. They make sure that each resident has their privacy. EVIDENCE: The home has a safe policy for the administration of medicines and all residents receive their medication at the right time. The home has changed suppliers which has improved the process and made sure that there is enough stock in the home to meet the needs of the residents. There are policies in place so that if anyone wanted to give themselves their medication they could do so safely. One resident said ‘he knew he could if he wanted but couldn’t be bothered.’ On the day of the inspection everyone was given their medication by the staff, safely and efficiently. Staff are polite and kind to the residents. They always knocked on flat doors and waited for an answer before going in. One resident said the staff ‘were available when you want them but they know when to leave you alone.’ At lunch one resident became upset and was asked if she would like to leave and Northbourne DS0000007401.V270441.R01.S.doc Version 5.0 Page 10 have a chat in her room. The incident was handled with care and concern, quietly and calmly. Other residents then were able to have their lunch as usual. The home was calm and settled with residents sitting in groups chatting, being involved in organised activities or having time in their rooms, whichever they preferred. Northbourne DS0000007401.V270441.R01.S.doc Version 5.0 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): 14 Residents are encouraged to make choices that affect their everyday life that helps them to keep control over their lives. Daily routines are flexible and staff help residents decide what to do with their day. EVIDENCE: Staff make sure that the residents are consulted and actively take part in making decisions about their lives as they talk to each resident on their own at least once a month about their own care plan. The resident decides what to do with their day, the staff help them to achieve that. Residents know who their keyworkers are and what they do. One resident said’ if there is anything I need that’s anything special I just ask my keyworker and they get it with no bother’. Another resident said ‘they come to talk to me and see if there is anything else I want to do’ Another resident goes out a lot to the pub and into the town and said ‘ they are all canny and always organise my trips out, nothing is too much trouble.’ Residents meetings are held monthly or when the residents decide there is anything important to talk about. Residents are encouraged to take part and make decisions about how the home is run. At these meetings residents decide when outings and activities are to take place. Northbourne DS0000007401.V270441.R01.S.doc Version 5.0 Page 12 One resident said ‘yes I know they happen but I don’t bother to go as I’m happy with the way things are’ Staff are understanding and ask the residents what they would like to do each day. They have good relationships with residents, showing an interest in what they do by chatting and being friendly. Residents are involved in deciding and writing their care plans. The care plans are reviewed every month by individual residents and their keyworkers to see if anything has changed in the residents lives. This ensures the residents needs are met. Residents are able to have keys to their flats if they want and where this is not possible a risk assessment is in place outlining the reasons why they can’t. Northbourne DS0000007401.V270441.R01.S.doc Version 5.0 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): These standards were not assessed during this visit as they were looked at last time. EVIDENCE: Northbourne DS0000007401.V270441.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Good systems are in place to ensure maintenance issues are addressed quickly and prevent inconvenience to residents. EVIDENCE: The home is well maintained by contractors who come when contacted for repairs and emergencies. During the inspection a toilet flooded, the staff locked it and put a safety notice on the door and called the contracted plumber who responded to the call out to the home within two hours. The toilet was repaired and back in use before the end of the inspection. All residents’ flats have very personal with items of residents’ own furniture and possessions. All were well decorated. All flats have had new letterboxes fitted to the doors that are safer to use with no sharp edges. The doors are to be painted and have no numbers. The temporary numbers are very hard to see. The manager agreed to have improved numbers made for the doors. The manager is investigating different ways of using colour and signs to help Northbourne DS0000007401.V270441.R01.S.doc Version 5.0 Page 15 residents find their way around the building. More ideas need to be put in place to make sure that residents recognise their own doors. Fire records and training are up to date. During the inspection a fire drill was held and all staff responded calmly, quickly and knew what to do. The residents said that the fire alarm was often tested. The staff did not know that the drill was to be held. There is a plan to alter the lay out of the lower level of the building that consists of service areas such as offices and laundry. The plan is to make a bedroom with en suite facilities for visitors so that they can stay. This will replace the existing bedroom that has facilities across the corridor. The administrators office is to be moved across the corridor and in doing so will be made bigger. There is also space provision for a dedicated medication room with storage. Work is scheduled to begin in the New Year. The home is clean throughout and does not smell. One visitor said ‘it is always clean and lovely’ The laundry is adequate to cope with laundry for 33 residents. A personalised laundry system is in place. However the door should be locked at all times when the laundry is empty as residents use that corridor to visit the administrator. Staff use the laundry as a thoroughfare to get to the newly designated smoking area outside the laundry back door. Staff were seen sitting inside the laundry back door and flicking their used cigarettes outside. This is dangerous. Outside the back door is an untidy area with an overflowing tin of used cigarettes and two old chairs. This area is in full view resident’s windows and one resident who has a room overlooking this area said ‘ it’s a shame as the rest of the place is lovely.’ The smoking policy in the home must be properly implemented and safe procedures must be put in place if staff are to smoke outside. Heating and light throughout the home are at safe levels. Water temperatures are monitored to make sure correct temperatures are maintained. Northbourne DS0000007401.V270441.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 The home is staffed to a satisfactory level with an appropriate staff mix which ensures the needs of each resident can be met despite the layout of the building. Recruitment procedures are robust therefore provide safeguards against the risk of abuse. EVIDENCE: The rota reflected the staffing in the home. Rotas are prepared well in advance and staff already knew their working hours and arrangements for over the Christmas and New Year period. There are no vacancies in the home at the moment. The staff are well supported by the manager who makes sure that all staff receive regular supervision which is shown in the staff records. One member of staff said that they regularly talked with the manager one to one and that the manager helped them to get on training courses and ‘helps sort out any issues I have.’ A satisfactory amount of support and ancillary staff are in post. The staff spoken to all knew about POVA (Protection of Vulnerable Adults) and what to do or how to spot any form of abuse. Regular training given. New starters are all made aware of how to keep residents safe then attend the course very quickly after beginning work in the Home Northbourne DS0000007401.V270441.R01.S.doc Version 5.0 Page 17 Three files were looked at of the most recently employed staff. All contained the correct required documentation and all had Criminal Record Bureau checks, two references, interview records and contract of employment therefore making sure that good practice is followed when recruiting staff to work with the residents. Staff spoken to on the day were happy, some had been there a long time and felt very settled. They said they had the training to do a good job and thought the way they worked revolved around the residents needs. Northbourne DS0000007401.V270441.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 The home is run in the best interests of the residents. There are policies in place that safeguard residents’ financial interests. EVIDENCE: Residents are involved in monthly meetings to decide future activities and outings. They talk about everything that happens in the home and residents said they are able to talk to any member of staff if they have a problem or something isn’t working out. Residents said they feel comfortable and content. Residents said’ nothing is too much trouble’ and ‘it’s a grand place, I can do just what I want.’ Visitors are able to come into the home whenever they want and can have privacy by using the residents rooms or can use small kitchens and lounges where refreshments are available at all times. Residents and relatives are asked for their views by questionnaires and surveys. Residents are well informed and have monthly care plan reviews to see if their needs have changed. Residents said they enjoyed their monthly Northbourne DS0000007401.V270441.R01.S.doc Version 5.0 Page 19 meetings and that staff always did as much as they could to make sure they were looked after the way they wanted to be. There is a suggestion box that can be used by anyone. Residents know who their key worker is and who to go to if they are unhappy. The home has recently changed the way they look after personal money for the residents. The home did not inform residents that the system for keeping their personal allowances was changing. They now operate a pool system. This means residents do not receive interest on the their monies. There is a system in place to show residents how much money they have in their account, and all transactions are recorded, electronically and on paper. Residents have access to pocket monies held in this account at all times as long as they are in credit. Two staff,as well as the resident if they are able, have to sign for any money taken out or put into the account. The administrator and manager explained the systems for keeping records of the residents finances and expenditure. The records are kept on the computer and in books which are kept up to date and clear. Information was easy to find. All records are kept locked away. The regional manager does regular audits of the system providing a second check of records from a person outside the home. Northbourne DS0000007401.V270441.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 3 x x X x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x 2 x x x Northbourne DS0000007401.V270441.R01.S.doc Version 5.0 Page 21 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 OP8 Regulation 12 & 13 Requirement All aspects of residents healthcare needs must be adequately assessed and appropriate measures implemented to meet their identified needs. (outstanding from last inspection) Smoking in the laundry area must cease Numbers to be displayed on bedroom doors. Timescale for action 30/04/06 2. 3. OP38 OP22 36 23 12/12/05 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Northbourne DS0000007401.V270441.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields 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.V270441.R01.S.doc Version 5.0 Page 23 - 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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