Inspection on 19/02/07 for Northbourne Court

This inspection was carried out on 19th February 2007.

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.

Other inspections for this house

Northbourne Court 01/09/08

Northbourne Court 16/07/07

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Northbourne Court Harland Avenue Sidcup Bexley DA15 3LJ Lead Inspector Pauline Lambe Unannounced Inspection 19th February 2007 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 Court DS0000067696.V325541.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 Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Northbourne Court Address Harland Avenue Sidcup Bexley DA15 3LJ 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) 020 8269 9840 020 8269 9841 terry.heslington@kcht.org.uk www.kcht.org Kent Community Housing Trust Susan Jacqueline Ilott Care Home 120 Category(ies) of Dementia - over 65 years of age (120), Old age, registration, with number not falling within any other category (120) of places Northbourne Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection First inspection since registration Brief Description of the Service: Northbourne Court is a purpose built care home for older people requiring personal care and older people with dementia. The registered care provider is Kent Community Housing Trust, which is a not for profit organisation and the home was registered on 13th September 2006. Accommodation is provided on two floors, all bedrooms are for single occupancy and have en-suite showers, toilets and washbasins and complies with the current environmental standards. The home is divided into four suites each with a named manager and a designated staff team. The suites are further divided into fifteen bed units each with its own lounge, dining room and suitable bathing facilities. Other communal areas include ‘the Piazza’ on the first floor. This area provides a meeting point for residents, a piano bar, a café, a hairdressing salon and internet facilities. This area enables residents and relatives to enjoy a snack and to have a drink as the home has a licence to serve alcohol. Outside there is ample parking space and pleasant garden areas for the residents to enjoy. Day care services were provided and although this part of the service is not registered its impact on resident care would be considered as part of inspection. The current weekly fees ranged from £410 to £484. Northbourne Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Four inspectors from the Commission undertook the site visit for this unannounced key inspection on 19th February 2007. The inspectors were in the home for approximately 9 hours. It was the first inspection of the service since registration. The manager was in charge of the home on the day and she and other staff assisted with the inspection. The inspection included a review of the information held on the service file, information provided in the pre-inspection questionnaire, a review of questionnaires returned by residents and relatives, spending time in four of the fifteen bed units, inspecting care and other relevant records and safety systems, talking to residents, staff and relatives and viewing the environment. Staff and residents moved from three homes run by the organisation to Northbourne Court. The process of merging the staff teams and recruiting additional staff will take time to manage. Feedback from residents was generally satisfactory but a number raised concerns about staffing levels and the lack of activities provided. Feedback from relatives was varied with no concerns being expressed about staff attitude, visiting arrangements or the complaints procedures. However a number of concerns were raised about staffing levels, lack of activities and use of signs to help residents with dementia. What the service does well: What has improved since the last inspection? What they could do better: Improvements were needed to care plans to ensure they reflect how all assessed needs will be met. Accident records must include details of the event and a system must be in place to record and follow up unexplained injuries sustained by residents. Northbourne Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 6 A risk assessment must be completed for residents who wish to manage their own medicines. Staff must ensure that adequate supplies of prescribed medicines are available so that residents do not miss doses. Management must ensure adequate arrangements are in place to provide suitable activities for residents. Complaint records must be kept in the home and available for inspection. Staff rosters must clearly show all staff on duty at any time and should be kept for the separate suites. In view of the concerns raised about staffing levels the registered person should review current staffing levels. All information required by regulation must be obtained for staff prior to starting work in the home. Safety and service certificates must be kept in the home and available for inspection. Management must ensure there is no risk of residents sharing toiletries and topical lotions. Items like this must not be stored in bathrooms and creams and lotions must have the name of the resident. Residents must have access to call bell leads, particularly when in bed, unless they have been assessed as unable to use these. Management should review the current arrangements for providing day care and ensure this does not impact in any way on the quality of life and privacy of residents. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Northbourne Court DS0000067696.V325541.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 Court DS0000067696.V325541.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3. Standard 6 did not apply to the service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A statement of purpose and service user guide was provided but the service user guide needed some amendments. Some residents and relatives said they received adequate information about the service but others said this was not the case. Residents were admitted to the home based on a pre-admission assessment, which was undertaken by the assessment officer and or a care manager from social services. EVIDENCE: A statement of purpose and service user guide was provided. Copies of the service user guide were seen in some of the bedrooms viewed. The service user guide should be reviewed as it contained some misleading information about the provider’s responsibility to the Commission. For example in relation to residents attending A&E department and staffing levels. Feedback received from relatives and residents varied with some saying they received adequate information about the service but others did not received this. Recommendation 1. Northbourne Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 9 The majority of residents in the home had moved there following the closure of three smaller homes run by the organisation. These residents were already assessed and placements considered suitable. During the moving process staff did re-assess some residents who were not appropriately placed or required nursing care. The organisation had a full time assessment officer who completed most of the pre-admission assessments. The assessment officer was also involved in assessing residents admitted to hospital prior to their return to the home. Suite managers said the role of the assessment officer worked well and they did not have any problems with it. Care manager assessments were seen on some of the care records viewed. All beds in the home were contracted to Bexley Council. Northbourne Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7 to 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments were prepared and reviewed for residents. However care plans must be improved to ensure they show how all resident’s assessed needs will be met. Staff must make efforts to involve residents in care planning. Systems were in place to ensure residents received appropriate healthcare. Some improvements were needed to accident reporting and follow up. Medicines were appropriately stored and managed satisfactorily. No concerns were noted or raised in relation to how staff respected the dignity and privacy of the residents. EVIDENCE: Eight care plans were viewed. The records seen contained care plans and risk assessments. Care plans varied in content with some more detailed than others about how assessed needs were to be met. For example some care plans did not provide adequate information about bathing, shaving, continence and catheter care or evidence of monitoring residents weight where concerns were identified about nutrition. Some risk assessments were not followed by staff for example one care plan said the residents required the help of two staff Northbourne Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 11 to aid mobility however the inspector observed this being done by one person. Inspectors were told that residents could pay a member of staff a fee to have nail care and facial hair removed. This was considered inappropriate and should be part of general personal hygiene care and included in a care plan and some did not include a night care plan. Some documentation seen had not been signed and dated. The care plan format did not include any way to evidence that residents were involved with care planning. The care plan format included a section on ‘daily routine’ and where completed provided good information on the residents personal preferences. Care plans were being reviewed and in some instances it was evident that some were done with relatives. The relatives of one resident seen during the inspection had not been involved in care planning and in fact did not know that these were in place. Requirement 1. Arrangements were in place to ensure residents had access to routine health care. All residents were registered with a GP, had access to a visiting dentist and a district nurse spent three days a week in the home. Staff aid they found this input supportive and beneficial to resident care. Private arrangements were in place to provide residents with chiropody and optical services. There was also evidence on the care records seen that residents had access to other healthcare professionals such as a dietician and a diabetic specialist. Accidents to residents were only recorded when a resident attended A&E or when they sustained an injury. There was no system in place to follow up unexplained injuries sustained by residents and some of the accident forms seen were not well completed. For example some were unclear as to the time of the accident and some did not provide adequate information. Twenty-two of the care staff had first aid certificates. The manager completed a monthly accident report for head office. Feedback from residents and relatives indicated an overall satisfaction with the standard of care provided. Requirement 2. Medicine management was inspected on four units. Boots supplied medicines in a monitored dose system and provided printed medicine administration charts (MAR charts). Medicines were appropriately stored on each unit. Senior staff administered medicines and had received relevant training on medicine management. Records were kept for medicines received, administered and returned to the pharmacy. Medication records for a number of residents were inspected on the four units visited and were found to be accurate. On Wordsworth suite it was noted that one resident managed their own medication. However there was no risk assessment completed or a care plan in place in relation to this. Also on this suite one relative said that due to some confusion her resident had not had prescribed medication for about a week. Requirement 3. Interactions observed between staff and residents were appropriate. Residents were well presented and those spoken with made positive comments about the staff. This applied to relatives also however some relatives, residents and staff raised concerns about staffing levels. Northbourne Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 to 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was little evidence to show that residents were provided with suitable and adequate activity sessions. Satisfactory arrangements were in place to ensure residents maintained contact with their family and friends. There was some evidence to show that residents were supported to make decisions however how this was done could be better recorded in individual care plans. Residents were provided with a varied diet and comments received about food varied with some people satisfied and some not. Management must ensure the provision of day care does not affect the resident’s quality of life or their privacy. EVIDENCE: The manager said that she was having problems in relation to activity staff. This was due to sickness and staff decision to reduce their working hours. The manager was aware that this issue must be addressed. The home had a selection of communal areas for residents to use. Each suite had its own lounge, on the first floor there was a meeting area, a piano lounge, an Internet café, a hairdressing salon, a gym area, a library, a ‘well-being’ room, a small activity room and a café staffed by volunteers. In the inspectors view the equipment provided in the gym was inappropriate for the residents and should Northbourne Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 13 be reviewed. The activity room was very small and only accommodated about six residents at a time. On the day of the inspection the home had a number of day care residents in. One care assistant was in charge of this group of service users and said that numbers ranged from two to twelve. Many of these service users required assistance with personal care and one person found it difficult to manage alone. Also these service users were using the activity room and or the gym, neither of which was appropriate and left the residents in the home without access to these areas. This matter must be addressed and management must ensure that the provision of day care does not affect the quality of life or privacy of the residents living in the home. The registered person should ensure the fire service and insurance company are aware of the service users receiving day care on the premises. Recommendation 2. Social care plans seen for residents were scanty and did not show what activities residents could or preferred to take part in. Also daily care records did not reflect that adequate or suitable activities were provided. Staff expressed concerns about the quality of activity material provided, for example they said that some of this had bits missing or was not suitable for the residents. Many of the residents, relatives and staff raised concerns about the lack of activities provided. This standard was not met and will be reviewed at the next inspection. Requirement 4. A number of relatives were seen during the inspection and said they were made to feel welcome when visiting the home. However a number said they had difficulty gaining access to the home after 17.00 hours when the reception staff left. The manager was aware of this issue and the need to address it. Relatives were aware of the complaints procedure. Residents were encouraged to choose a meal, to say where they wanted to spend their time and staff respected their right to refuse care if relevant. Residents had access to a telephone. There was evidence is some of the care plans seen to show that residents were encouraged to make decisions about their lives. For example some included times for getting up in the morning and going to bed. Feedback from residents indicated that staff listened to them. As this is a new build there were no problems identified with the kitchen. It was adequately staffed, had appropriate equipment, had adequate storage and was clean and tidy. A cleaning schedule was in place and four weekly menus were prepared. Staff were aware of and able to meet resident’s special dietary needs such as vegetarian and diabetic meals. Menus given to the Commission indicated that a varied and nutritious diet was provided. In fact staff felt that having a cooked breakfast every day might not be suitable for the residents as regularly many residents were unable to eat their lunch. Food and drinks were available to residents in the suite kitchenettes at all times. Lunch was observed in four suites. All suites had a separate dining room. Tables were nicely laid with tablecloths, napkins, condiments and cutlery. Meals were brought to the suites in heated trolleys. Staff wore appropriate protective clothing while working in the dining rooms. Most residents had Northbourne Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 14 lunch in the dining room but those who were unable or preferred to had their meal in their room. Residents choose their meal the day before and if they did not like what was on offer could ask for an alternative. Comments made to inspectors varied about the quality of food provided with some people satisfied and some not so. During lunch on the day of the inspection meals were nicely served, residents were supported and encouraged to eat their meal and staff were attentive. Pureed foods were served separately and juice and water was available on the tables. However on Wordsworth suite one member of staff went off sick, which left one carer to serve 15 residents their meal and provide assistance where needed. No additional help was provided to the suite. On Chaucer Suite a number of residents ate none or very little of their meal. Staff said that this was not unusual. In view of the comments made by staff maybe having a cooked breakfast every day followed by a 12.30 lunch was too much for residents and should be reviewed. It is also important to ensure a system is in place to monitor residents weight on a regular basis. Requirement 5 and recommendation 3. Northbourne Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures were in place in relation to complaints and adult protection. Some improvements were needed to complaint records. EVIDENCE: A complaints procedure was provided and included in the statement of purpose. A record of complaints was kept in the home but this was hard to assess as some of the information was held at head office. For example in some instances the original complaint was not available to view so it was not possible to assess how well the complaint was managed. Since the home opened nine complaints had been made about the service. Some of the complaints were in relation to contacting or gaining access to the home. Steps had been taken to resolve this issue. A number of complaints were made about the staffing levels in the home. Requirement 6. A policy and procedure was provided in relation to adult protection. Staff training on this topic varied as staff form three homes moved to Northbourne Court. A number of staff had achieved NVQ level 2 qualification, which included training on adult protection. Staff spoken to had a good understanding of adult protection and how to manage such a situation. Northbourne Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment was finished to a good standard. Adequate bathing facilities were provided. Bedrooms were clean, tidy and personal and residents were satisfied with the environment. Ample communal space was provided. Satisfactory systems were in place to manage infection control and laundry. Handrails fitted in corridors could pose a risk to residents and others and the signage was not considered suitable for residents with dementia. EVIDENCE: The home is a new build and as such has a builders guarantee. The home complied with the current environmental standards and was bright, light and cheerful and decorated and furnished to a good standard. A wide range of communal space was provided and accessible to residents. Lifts were provided to give residents access to both floors. Two main concerns were noted in relation to the environment. One was the handrails fitted in the corridors, which had very shape corners and posed a risk to residents and others. Two Northbourne Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 17 people, one a resident and one a member of the ambulance crew had already sustained injuries because of the design. Maintenance staff had identified this risk and were slowly working through the building to ‘round’ the corners. However with so many to change this will take some time. The other issue was in relation to signage and identification of rooms for residents with dementia. All corridors and doors were the same colour, signs on toilets, bathrooms and bedroom doors were very small and placed out of resident’s direct line of vision. Bedrooms were identified with the resident’s name and their photograph. These signs were placed out of the direct line of vision and residents with dementia may not recognise themselves in recent photographs. It was disappointing that these issues were present, as they should have been addressed in the design and decoration stage especially as the home was built to accommodate a high number of residents with dementia. Requirement 7. All bedrooms had en-suite units with a shower, toilet and hand basin, which residents liked. Nine bathrooms with assisted baths were also provided. In some bathrooms there were unlabelled toiletries and topical applications. Recommendation 4. Bedrooms seen were clean, tidy, and comfortable and many personalised with the resident’s belongings. Residents and relatives were very satisfied with the environment. A number of bedrooms seen did not have call leads provided for residents to use particularly when in bed. Management should consider how relevant these are to resident safety and security and ensure they are made available based on an assessment of the resident’s ability to use them. Recommendation 5. Each suite had its own sluice area. Appropriate facilities and protective clothing was provided to enable staff to practice infection control management. Two laundry areas were provided, the main laundry for the home and a smaller one for residents to use. Both laundry areas were appropriately fitted. The main laundry was staffed from 08:00 – 16:00 every day. Staff spoken with confirmed they had received relevant training and displayed an awareness on prevention of the spread of infection. Northbourne Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 to 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A number of concerns were raised or noted in relation to staffing levels. Management must ensure staffing levels are reviewed to ensure they adequately meet the needs of the residents. Almost 50 of care staff had NVQ level 2 qualifications. A training programme was available and staff spoken indicated they were satisfied with the training provided. Information obtained for volunteers complied with regulation but some improvements were needed to ensure all relevant information was included in staff personal files. EVIDENCE: Staff who moved from the homes that closed were finding the current staffing levels inadequate. Some staff were quite stressed about this situation and one spoken to was close to tears. Examples given by staff of the impact of staff shortage was that often they had to stop one activity such as giving residents tea to assist a resident who needed personal care. Staff also said they felt anxious and rushed when giving care in the time available and often residents had to wait for care and assistance. A number of residents and relatives raised concerns about staff shortage. The inspector was told that the current staffing rosters were planned for each 30-bed suite and the suite manager hours were not included in the care hours. Currently the home relied heavily on bank and agency staff to cover shifts. Permanent staff said that this added to their workload as at times they found that agency staff did not contribute adequately and did not know the residents or their routines. One additional Northbourne Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 19 staff member was on duty between 11:00 and 14:00 daily to assist with serving meals. However this was not evident on Wordsworth or Chaucer suites on the day of the inspection. An additional carer was on duty between 07:00 to 11:00 and between 17:00 to 21:00 on each suite. However some staff said that this additional carer was not always on duty. There was also some confusion about staffing on suites during hand over time. For example on the day of the inspection there were no care staff on Chaucer suite for a period of time during shift change over. Rosters seen for one week supported the current staffing levels as verbally confirmed by the manager. However in view of the comments made management must review staffing levels and change these if needed. The staff rosters seen did not include the hours the suite managers were on duty, did not have staff full names and did not clearly identify agency and bank staff. The manager said they she was looking at introducing a more suitable staff roster to ensure these accurately reflect all staff on duty at all times. Requirement 8 and recommendation 6. Eighty-eight care staff were employed and forty of them had NVQ level 2 qualification or above. The organisation was committed to providing NVQ training for all care staff. A recruitment policy and procedure was provided together with a policy on equal opportunities. In view of the high use of bank and agency staff management were actively recruiting care and activity staff. No new staff had been recruited and the staff team comprised of staff transferred from the homes that were closed. Four staff and six volunteer files were inspected. Staff files seen did not contain all the information required by regulation. Administration staff said that they were reorganising personal files and as part of this process would update all files. The volunteer files inspected contained all the relevant information. Plans were in place to provide volunteers with photographic identity badges to use then they were in the home. Requirement 9. Staff spoken with indicated they were satisfied with the training provided. Training records viewed showed that recent training included safe moving & handling, food hygiene and first aid. Staff training will be reviewed at future inspections to ensure staff have access to annual and appropriate training once staffing has settled and records organised. Northbourne Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager was registered with the Commission and had other senior staff to support her in her role. A quality assurance system was in place. Satisfactory systems were in place to safely manage resident’s personal finances however more care must be taken to ensure records were kept for other items belonging to residents stored in the safe. From the evidence provided attention was given to providing a safe environment for residents and others. EVIDENCE: A full time manager was in post and registered with the Commission. Each suite had a named manager and a ‘hotel services’ manager was in post. The staff team included team leaders care assistants, domestic and ancillary staff. Northbourne Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 21 The organisation had a recognised quality assurance system in place. The home was due for its first assessment in March 2007. The system in place did not review resident and relative satisfaction. The registered person planned to send an annual satisfaction questionnaire to residents and relatives. The organisation had obtained the Investors in People recognition. The Commission received regulation 26 reports. No relative or resident meetings had been held since the home opened. Satisfactory systems were in place to manage resident’s personal money. Records were kept for money received and removed from resident’s individual accounts. Receipts were kept for purchases made on behalf of residents such as hairdressing and chiropody. No regular checks or audits had been carried out on resident financial records since the home opened. A record was also kept of valuables held for residents however the information recorded was inadequate. For example they did not specify the number or details of the items held. It was therefore not possible to confirm that the articles held were there. Requirement 10. A health and safety policy was provided. Two full time maintenance technicians were employed to provide routine maintenance and an on call service in emergencies. Staff recorded repairs and health and safety issues and the technicians addressed this on a daily basis. As the home was recently constructed it had a builders guarantee to address any major maintenance issues. Adequate systems were in place to ensure the safety of residents and others. Safety records seen showed that routine maintenance was being provided. For example up to date service certificates were seen for fir, gas, electricity, assisted baths and lifts. The manager could not locate all the safety certificates for the moving and handling equipment as some of this had been brought from the homes that closed. Fire safety systems were in place and the last fire drill was held on 29/22/06. The fire drills records should include the full date, time and staff response. Recommendation 7. Northbourne Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 22 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X 3 X X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Northbourne Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? First 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 Standard OP7 Regulation 15 Requirement The registered person must ensure a care plan is prepared to show how assessed needs will be met and where possible the resident must be included in this process. Care must be taken to sign and date documentation. Residents must not be asked to pay for routine personal care such as nail cutting and removal of facial hair. A system must be in place to monitor resident’s weight. The registered person must ensure accurate records are kept for all accidents to residents. A system must be in place to follow up unexplained injuries sustained by residents. The registered person must ensure that a risk assessment and care plan is prepared for residents who choose to manage their own medicines. Adequate supplies of medicines must be obtained to ensure residents do not miss doses of prescribed medicines. DS0000067696.V325541.R01.S.doc Timescale for action 16/04/07 2 OP8 17 16/04/07 3 OP9 13 16/04/07 Northbourne Court Version 5.2 Page 24 4 OP12 16 5 OP15 18 6 OP16 17 7 OP19 23 8 OP27 18/17 The registered person must ensure residents have access to suitable and adequate social activities. Adequate staffing levels must be maintained to manage activities. Care plans must be prepared to show how resident’s social needs will be met and must involve residents or their relatives in their preparation. Equipment provided for activities must be appropriate and fit for the residents to use and enjoy. The provision of a day care service in the home must not affect the lifestyle or privacy of the residents who live there. The registered person must ensure that there is adequate staff on duty to ensure residents have the assistance and support they need to enjoy their meal. The registered person must ensure that the records for all complaints made about the service are kept in the home and available for inspection. The registered person must ensure risks to the health and safety of residents are identified and as far as possible eliminated. Action must be taken to reduce the risk of injury from the sharp corners on the corridor handrails. Signage of areas such as toilets, bathrooms and bedrooms must be improved for residents on the dementia units. The registered person must ensure accurate rosters are kept to reflect all staff on duty at any given time. Rosters must include all staff on duty, their full name and designation. DS0000067696.V325541.R01.S.doc 16/04/07 16/04/07 16/04/07 16/04/07 16/04/07 Northbourne Court Version 5.2 Page 25 9 OP29 19 10 OP35 13 In view of the concerns raised about staffing levels management must review these and ensure the staffing levels maintained adequately meet the needs of the residents. The registered person must ensure that all information required by regulation is obtained for staff working in the home and is available for inspection. The registered person must ensure a detailed list of valuables held in the safe on behalf of residents must be kept and checked at regular intervals. Efforts must be made to return such items to residents or relatives when appropriate. 16/04/07 16/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations The registered person should review the service user guide and ensure any information about the role of the Commission is accurate. Efforts should be made to provide all residents with a copy of the service user guide. The registered person should ensure the fire service and insurance company are aware of the service users receiving day care on the premises. The registered person should review meals and meal times to ensure this suits the needs of the residents and enables them to enjoy their main meal of the day. The registered person should ensure toiletries are not left in the bathrooms and that all topical medications are labelled and used for one resident only. The registered person should ensure call leads are provided for residents in their bedrooms and if this is not appropriate then the decision not to provide them should DS0000067696.V325541.R01.S.doc Version 5.2 Page 26 2 3 4 5 OP12 OP15 OP21 OP24 Northbourne Court 6 OP27 7 OP38 be supported by a risk assessment. The registered person should review the current format for recording staff rosters. The current format was confusing and copies of rosters provided did not enable the Commission to review the staffing levels on individual suites. The registered person should ensure all safety records are available for inspection and fire drill records are full dated, include the time and staff response. Northbourne Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Northbourne Court DS0000067696.V325541.R01.S.doc Version 5.2 Page 28 - 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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