Inspection on 01/06/05 for Northernhay

This inspection was carried out on 1st June 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

Northernhay 29/06/09

Northernhay 31/05/07

Northernhay 21/03/06

Northernhay 30/11/04

Northernhay 20/07/04

Northernhay 13/01/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Northernhay Townstall Pathfields Dartmouth Devon TQ6 9HL Lead Inspector Peter Wood Announced 01 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Northernhay D54-D07 S3761 Northernhay V223525 010605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Northernhay Address Townstal Pathfields Dartmouth Devon TQ6 9HL 01803 833964 01803 835186 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Jane Susan Garland Mrs Jane Susan Garland Care Home 18 Category(ies) of OP registration, with number of places Northernhay D54-D07 S3761 Northernhay V223525 010605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 30/11/04 Brief Description of the Service: Northernhay is a converted and extended care home, set in a residential area, above the town of Dartmouth.The home is able to provide accommodation for up to eighteen older people over three floors, following the recent creation of three extra en-suite rooms on the lower ground floor and the re-registration of a large single back to its original double status. The first floor is accessed via a passenger lift and the lower ground floor by a newly fitted stair lift. On the ground floor is one large lounge and a separate sun lounge plus a dining room. The home has bathing aids, mobile hoists and thirteen of the sixteen single bedrooms are en-suite, as is the one double. There are a further four WCs. There is an assisted bathroom on the lower ground floor and there is also an assisted bathroom on each of the other floors. The home’s kitchen is in the process of being completely upgraded, which will almost double its size. The home has attractive gardens front and back. Northernhay D54-D07 S3761 Northernhay V223525 010605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place on a weekday in June 2005. The manager had previously completed a Pre-Inspection Questionnaire. The owner and manager assisted the inspection throughout. I took lunch with some residents and consulted others in the lounge or their own room. All residents were seen and asked for their views of their experience of living at this home. A visiting relative was also asked for his comments. Additionally a small number of Comment Cards were received from residents, relatives and visitors to the home. Care staff on duty were observed and some consulted about their experience of working in this home. A complete tour of the home was undertaken and a sample of care and other records was examined. What the service does well: What has improved since the last inspection? Four Requirements were made at the previous inspection, all of which had been made on previous occasions. Some action has been taken towards compliance. Progress is reported below: • The owner said she would include the qualifications and experience of the owner and staff and service user views of the home in the statement of purpose and service user guide when staff have obtained the qualifications for the courses currently being undertaken. Previous timescales of 21/09/04 and 30/01/05 not met. The owner said that all radiators to which service users may have access continue to be fitted with radiator covers, in order of risk priority. Some are never turned on (as they are not needed). Previous timescale of 21/11/04 and 30/01/05 not met. D54-D07 S3761 Northernhay V223525 010605 Stage 4.doc Version 1.30 Page 6 • Northernhay • The owner has removed some hot taps to prevent residents turning on the hot water and possibly becoming scalded. The requirement made at previous inspections, that the Home’s hot water supply must be regulated to 43 degrees Centigrade, on the first floor, where there is full body immersion and risk assessed in relation to individual service users hand basins and regulated as necessary, has not been met. Previous timescale of 21/11/04 and 30/01/05 not met. The owner has not carried out a Legionella risk assessment. Previous timescale of 21/11/04 and 30/01/05 not met. • There were also a eight Recommendations. Some action has been taken towards compliance. Progress is reported below: • The owner has received and acted upon the report from an occupational therapist who visited the home to assess and advise on the adaptation and disability equipment provided. The registered person has asked residents whether they want locks, which have been universally declined. The registered provider agreed to ensure that the staffing rota, within the home, is in a format that is easy to understand and that all staff’s hours are documented, including her own, when these hours constitute part of the required staffing levels. The recommendation that the home must include individual staff photographs, within each staff member’s file remains outstanding. The recommendation that the registered person should continue to ensure that first aid training is provided to allow a first aid qualified staff member to be on duty at all times remains outstanding. The registered person has undertaken a questionnaire of stakeholders to ensure quality assurance within the home is monitored and maintained. The recommendation that the registered person should have a business and financial plan available for inspection remains outstanding. The recommendation that the registered person should ensure that there are detailed records of the supervision provided to the staff remains outstanding. • • • • • • • Northernhay D54-D07 S3761 Northernhay V223525 010605 Stage 4.doc Version 1.30 Page 7 What they could do better: There are five Requirements, all made on previous occasions (one as a Recommendation), albeit that some action has been taken towards compliance: • The home’s statement of purpose and service user guide must include the qualifications and experience of the owner and staff and service user views of the home. Previous timescale of 21/09/04 and 30/01/05 not met. All radiators to which service users may have access must continue to be fitted with radiator covers. Previous timescale of 21/11/04 and 30/01/05 not met. The Home’s hot water supply must be regulated to 43 degrees Centigrade, on the first floor, where there is full body immersion and risk assessed in relation to individual service users hand basins and regulated as necessary. Previous timescale of 21/11/04 and 30/01/05 not met. The home must carry out a Legionella risk assessment. Previous timescale of 21/1104 and 30/01/05 not met. The registered provider should ensure that staff files contain photographic proof of identity. • • • • There are also five Recommendations, all made on previous occasions: • The registered person should provide a suitable lock and key to each resident’s bedroom unless it is recorded in the care plan that the resident has specifically declined this, or has been risk assessed as unable to use this. The registered provider should ensure that the staffing rota, within the home, is in a format that is easy to understand and that all staff’s hours are documented, including her own, when these hours constitute part of the required staffing levels. The registered person should ensure that first aid training is provided to allow a first aid qualified staff member to be on duty at all times. The registered person should have a business and financial plan available for inspection. The registered person should ensure that there are detailed records of the supervision provided to staff. • • • • Northernhay D54-D07 S3761 Northernhay V223525 010605 Stage 4.doc Version 1.30 Page 8 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. Northernhay D54-D07 S3761 Northernhay V223525 010605 Stage 4.doc Version 1.30 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Northernhay D54-D07 S3761 Northernhay V223525 010605 Stage 4.doc Version 1.30 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4, 5 Thorough and comprehensive systems for admission allow service users and their relatives to be confident that their needs can be met. EVIDENCE: The home continues to fully meet the assessed needs of the service users living at the home in a satisfactory manner, taking into account service users’ individuality and personal preferences. The manager undertakes a preassessment prior to a resident’s admission, followed by detailed assessments that generate comprehensive care plans. The home’s statement of purpose and service user guide should include the qualifications and experience of the owner and staff and service user views of the home. Northernhay D54-D07 S3761 Northernhay V223525 010605 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10, 11 Service users health, personal and social care needs are met and residents are treated respectfully. The home’s practices relating to medication administration protect the residents from harm. EVIDENCE: Service users’ privacy and dignity continues to be upheld at all times. All aspects relating to providing for service users primary health care needs were well maintained. The administration of medication within the home is satisfactory. Detailed Care Plans are drawn up for all residents, generated from comprehensive assessments. Residents can self medicate subject to a satisfactory risk assessment. Residents were observed to be, and reported that they were, treated with respect by staff. Northernhay D54-D07 S3761 Northernhay V223525 010605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 Social activities are managed well and provide daily interest for the service users. Meals are nutritious and varied. EVIDENCE: The routines within the home continue to be very flexible and take into account individual service users’ lifestyle preferences. Friends and families are welcomed and encouraged to the home. Resident’s rooms reflected their personality, some of which contained items of their own furniture as well as smaller personal items. Residents told me that they were able to get up and go to bed at whatever time they wished. Those with relatives who lived locally enjoyed being visited and taken out by them, while some others said they would like to be taken out by staff more often than they were. Some residents said they would like more activities. The lunchtime meal taken in the very pleasant dining room was attractive, with choice offered, and understood to be nutritious. Northernhay D54-D07 S3761 Northernhay V223525 010605 Stage 4.doc Version 1.30 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 standard(s) 16, 17, 18 Complaints and suggestions from service users, relatives or other visitors to the home, are treated seriously. Service users are listened to and issues resolved promptly. EVIDENCE: The home has not had any complaints within the last twelve months. The home has adequate adult protection documentation and staff receive appropriate training in this area. The home does not become involved in any resident’s finances other than holding small amounts on behalf of relatives to pay for such items as hairdressing and toiletries. Most are subject to (Enduring?) Power of Attorney. Northernhay D54-D07 S3761 Northernhay V223525 010605 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 23, 24, 25, 26 The service users live in a very pleasant, well-maintained clean home that is comfortable and warm and which provides sufficient facilities to meet their needs. However, the lack of suitable protection from hot water, hot surfaces and Legionella could put residents at risk. EVIDENCE: The home’s environment provides accommodation that is well maintained, clean and comfortable. The registered person should provide a suitable lock and key to each resident’s bedroom unless it is recorded in the care plan that the resident has specifically declined this, or has been risk assessed as unable to use this. All radiators to which service users may have access must be fitted with radiator covers. The Home’s hot water supply must be regulated to 43 degrees Centigrade, on the first floor, where there is full body immersion and risk assessed in relation to individual service users hand basins and regulated as necessary. Samples of hot water measured during the inspection included one at 55oC, while another was off the scale. The home must carry out a Legionella risk assessment. Northernhay D54-D07 S3761 Northernhay V223525 010605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 Service users are cared for by well-trained and motivated staff in sufficient numbers to meet the needs of those currently living in the home. Recruitment processes protect vulnerable service users. EVIDENCE: The care staffing levels in the home continues to meet the previously agreed Guidance levels issued by the previous Registering Authority. The home’s recruitment procedures were satisfactory and the home had a satisfactory training programme in operation. Staff were seen to be carrying out their duties in a professional, sensitive manner whilst service user feedback, as well the visitors feedback, was very complimentary regarding the care and attention given by all members of the home’s staff team. At the present time three of the six care staff (50 ) have NVQ 2 or above, equal to the target to be reached by (the end of?) 2005. However, two of these have NVQ 4, and others will soon complete their training. The home is hoping to achieve 100 trained staff soon. Northernhay D54-D07 S3761 Northernhay V223525 010605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 36, 37, 38 Service users live in a well managed home. The owner, manager and their staff team strive to provide a homely environment that respects and protects service users’ rights. EVIDENCE: The home’s policies and procedures were seen to be in order, being well presented, up to date and well maintained. The home’s quality assurance system has been improved in that a questionnaire has been sent to stakeholders to ensure that a continual form of self monitoring takes place. The home did not have a written business and financial plan. Written staff supervision records were not available. The home’s health and safety was mostly in order with the exception of full water regulation throughout the home, covering of all hot surfaces throughout the home and the undertaking of a Legionella risk assessment. Northernhay D54-D07 S3761 Northernhay V223525 010605 Stage 4.doc Version 1.30 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 3 3 2 Northernhay D54-D07 S3761 Northernhay V223525 010605 Stage 4.doc Version 1.30 Page 18 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4 Requirement The home’s statement of purpose and service user guide should include the qualifications and experience of the owner and staff and service user views of the home.(Previous timescale of 21/09/04 and 30/01/05 not met). All radiators to which service users may have access must continue to be fitted with radiator covers. (Previous timescale of 21/11/04 and 30/01/05 not met). The Home’s hot water supply must be regulated to 43 degrees Centigrade, on the first floor, where there is full body immersion and risk assessed in relation to individual service users hand basins and regulated as necessary. (Previous timescale of 21/11/04 and 30/01/05 not met). The home must carry out a Legionella risk assessment. (Previous timescale of 21/11/04 and 30/01/05 not met). The staff file should include photographic proof of identity. Timescale for action 01/09/05 2. 25 13 01/09/05 3. 25 13 01/09/05 4. 25 13 01/09/05 5. 29 19, Sch 2 01/09/05 Northernhay D54-D07 S3761 Northernhay V223525 010605 Stage 4.doc Version 1.30 Page 19 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 24 Good Practice Recommendations The registered person should provide a suitable lock and key to each resident’s bedroom unless it is recorded in the care plan that the resident has specifically declined this, or has been risk assessed as unable to use this. The registered provider should ensure that the staffing rota, within the home, is in a format that is easy to understand and that all staff’s hours are documented, including her own, when these hours constitute part of the required staffing levels. The registered person should have a business and financial plan available for inspection. The registered person should ensure that there are detailed records of the supervision provided to staff. The registered person should ensure that first aid training is provided to allow a first aid qualified staff member to be on duty at all times. 2. 27 3. 4. 5. 6. 34 36 38 Northernhay D54-D07 S3761 Northernhay V223525 010605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton Devon TQ13 7UP 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. 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