Inspection on 26/09/05 for Northbourne

This inspection was carried out on 26th September 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 21/12/05

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 Sharon McDowell Unannounced Inspection 26th September 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Northbourne DS0000007401.V250515.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.V250515.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.V250515.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th December 2004 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.V250515.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted as part of the annual inspection programme and lasted six hours in total. During the inspection six residents, five staff and two relatives were spoken with. The Registered Manager was on duty and was present throughout the inspection. A number of documents were reviewed as part of the inspection, including two residents care plans, staff training records, training resources and maintenance records. Lunch was shared with the residents in the dining room. What the service does well: What has improved since the last inspection? In response to some similar incidents, which affected residents, the Registered Manager has implemented ways to ensure residents property and money is safeguarded. This has been discussed with residents and relatives to ensure they are kept informed about how things are being dealt with. The organisation of the ‘friends of Northbourne’ group is viewed as a positive step to involve residents and relatives in the running of the Home. One relative had been particularly supportive of the Home by writing letters to the Registered Provider about the state of the garden area, which helped get agreement to tidy the area up. Northbourne DS0000007401.V250515.R01.S.doc Version 5.0 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.V250515.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.V250515.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): 3 The Home obtains sufficient information about prospective residents to be able to make a judgement as to whether the Home can meet their needs. EVIDENCE: Care manager assessments are available in the residents care plans demonstrating that their needs are assessed prior to them being considered for accommodation at the Home. This also means the staff can make a judgement as to the suitability of the Home and if staff can meet the prospective residents needs. Where there is no care manager assessment the Registered Manager will complete a company assessment. This is particularly for those residents who are funding their own care and do not have a care manager. Northbourne DS0000007401.V250515.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): 7, 8 Care records demonstrate that resident’s health and social care needs are documented and that staff enable residents to access health care services. Therefore residents can be assured their health and well-being is attended to on the majority of occasions. However there are some instances where staff are not knowledgeable about some aspects of healthcare therefore residents health needs might not be taken care of. EVIDENCE: The Registered Manager explained that a new care plan format is to be introduced into the Home. This is to follow a ‘getting to know you’ process, which means staff will spend some time with residents finding out about what their life has been like, how it is now and how they would like it to be in the future. The local dementia care specialist is to be involved in this to support staff during the implementation. District nursing records are maintained in the Home providing evidence that residents have access to local health care services. Other health professionals coming in to the Home include Macmillan nurses, GPs and chiropody. Some staff have had training at a local NHS hospital in palliative care and plan to do further training, which will enhance their skills when dealing with residents who Northbourne DS0000007401.V250515.R01.S.doc Version 5.0 Page 10 have a palliative care condition. Information is available in the main office about diabetes for staff to refer to. Two staff have completed the trainers course in diabetes, therefore they can teach staff about diabetes. A questionnaire is given to staff, which is marked by the district nurse and a certificate issued when staff have successfully completed the questionnaire. One resident had not been able to receive their medication for epilepsy, as it had not arrived from the pharmacy. They had been without their medication for two days, which could have had an impact on epilepsy and caused them to have seizures. During lunch it was noted that a resident appeared to be having some form of seizure, in that they were almost asleep. When staff were asked about this, they said the resident was often like this. In discussion with the Registered Manager it was explained the resident did have epilepsy and that some blood tests were being carried out to measure anticonvulsant levels. However the resident was only seen by their GP. Advice was given to contact the local NHS Trust for advice about specialist epilepsy services. A document was displayed in the office, which gave details of any clinical tests that individual residents had, for example, blood and urine tests. The results were recorded on the sheet. The reason behind the document was to ensure that staff followed up tests so they could monitor the resident’s care. However it was suggested this be kept somewhere more discreet as it held residents personal details. The Home is due for redecoration and the Registered Manager explained she has consulted the sensory impairment team for advice about the design of the redecoration so that the environment is easier to get around by those people who have a sensory impairment. Northbourne DS0000007401.V250515.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): 12, 13, 15 Staff support residents to participate in a range activities so that they can enjoy an interesting and stimulating lifestyle. However at times the social programme is not implemented sufficiently to meet the needs of the residents accommodated. Visitors are welcome to the Home therefore residents can be assured they will be able to keep in touch with their relatives and friends. Residents are provided with nutritious homemade meals, which contributes to their health, well being and enjoyment. EVIDENCE: The Home has a ‘Friends of Northbourne’ group set up, which involves relatives and residents. So far there have been three meetings and minutes available for people to read. Issues discussed have included arrangements for a summer fayre, staffing, name badges for staff and activities, which shows that residents and relatives are involved in issues affecting the Home. A comments book is available in the main entrance to the Home for people to write their comments and suggestions in about their views of the Home. The home has also recently commissioned an external agent to conduct a customer satisfaction survey to obtain their views about the care and services in the Home. Northbourne DS0000007401.V250515.R01.S.doc Version 5.0 Page 12 The home does not employ an activity organiser, as care staff are responsible for arranging social events. Some of the residents go out to a dance every week and a variety of other activities are attended by individuals and groups of residents including the gym, day centres and visits to other Homes to join in their entertainment events, such as singers and bands. One of the residents said how they did not want to get involved with activities; they liked to sit and watch what was going on and to watch television. The independent survey states that social activities are not adequate, with comments from relatives, such as, ‘there is a list of activities but they are often not carried out’ and ‘more organised activities and outings are needed, also more entertainment’. One visitor said how they ‘couldn’t fault the Home, the staff are good, food is good, infact too good as you put weight on’, they were pleased to say that staff took there relative out for walks and that the Home was always clean with no odours. They liked the ‘friends of Northbourne’ group as they felt they got to know what was going on in the Home. Residents were assisted to the dining room by staff and were able to sit with their friends in the Home. The dining room is spacious and very pleasantly decorated offering a comfortable area for the residents to eat their meals. The choice of meal was braised steak and vegetables or salad and for dessert was homemade rhubarb crumble. The food was plentiful, served from a hot trolley so that it was hot for the residents. The cook explained that all the meals are home made, for example, baked hams, pies and cakes. The residents made positive comments about the meals, such as, ‘can’t fault the food, it’s very good’. Northbourne DS0000007401.V250515.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): 16, 18 Residents and their relatives can be assured their concerns will be listened to and dealt with in an appropriate manner. Adequate measures are in place to promote the safety and well being of residents and to protect them from harm. EVIDENCE: The complaints procedure is available to residents and their visitors telling them how to make a complaint and who to. There have been three complaints recorded in the complaints register since the previous inspection, which have all been investigated and resolved with the people raising the concerns. The Home has informed the Commission for Social Care Inspection through regulation 37 notifications of a number of similar incidents, which have been appropriately referred to the correct agencies for assistance with investigation of the alleged events. Residents have been kept well informed and have been given advice about how to reduce the risk of these events reoccurring. All but five staff have now attended training in Protection of Vulnerable Adults with the Local Authority Protection of Vulnerable Adults coordinator. Further training is to be organised. Policies and procedures are available in the home to guide staff as to what to do in the event of suspected or actual harm to a resident. Northbourne DS0000007401.V250515.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): None of these standards were assessed during this visit therefore will be reviewed at the next inspection. EVIDENCE: Northbourne DS0000007401.V250515.R01.S.doc Version 5.0 Page 15 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): 30 Staff are supported to attend relevant training to enable them to fulfil their roles. Therefore residents and relatives can be assured they will have their needs met by staff that know how to look after them. EVIDENCE: A training plan is displayed on the office wall demonstrating a range of training that has been arranged for the staff, including topics, such as, Protection of Vulnerable Adults, health and safety, diabetes and back care. Individual training records with certificates of attendance are maintained in staff personnel files. These include details of induction training and mandatory training. Therefore ensuring that staff have the right skills to do their job. The Registered Manager explained that there is a training package to be implemented about care of people with dementia. This has a resource pack that is helpful to relatives, explaining what is happening to someone with dementia and why they might behave in the ways they do. It gives practical advice about how to stay involved with their relative when they go into care and the impact of a move of home for the person with dementia. Northbourne DS0000007401.V250515.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 38 The Registered Manager is suitably experienced and qualified to manage the care home in the best interests of the residents accommodated at the Home. Adequate measures are in place to protect the health and well-being of residents through implementation of health and safety checks. EVIDENCE: The Manager is suitably qualified and experienced to run a care home. She has many years experience in care homes and continues to update her knowledge, skills and competence. She has completed the Registered Managers Award qualification, which is required by the National Minimum Standards to promote managers having a good level of knowledge of management processes. A maintenance file is kept in the home, which has copies of all the relevant certificates of servicing of equipment and amenities, such as gas, electric and Northbourne DS0000007401.V250515.R01.S.doc Version 5.0 Page 17 hoists. A fire risk assessment has been completed and updated to help identify any areas pf concern in the Home and what action is required to reduce risk. First aid equipment is checked and a list of trained first aid staff is attached to the first aid box so that appropriately trained staff are available to deal with first aid incidents. Northbourne DS0000007401.V250515.R01.S.doc Version 5.0 Page 18 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 2 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 3 Northbourne DS0000007401.V250515.R01.S.doc Version 5.0 Page 19 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 Timescale for action 30/11/05 2 OP8 13(2) 3 OP12 16(2)(n) All aspects of residents healthcare needs must be adequately assessed and appropriate measures implemented to meet their identified needs. Prescribed medication must be 26/09/05 available at all times and where this is not possible the resident’s doctor must be consulted for advice. Adequate social activities must 30/11/05 be provided to meet the needs of the residents accommodated. 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 OP8 Good Practice Recommendations Staff should receive training in epilepsy and care of residents with this condition. Northbourne DS0000007401.V250515.R01.S.doc Version 5.0 Page 20 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.V250515.R01.S.doc Version 5.0 Page 21 - 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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