Inspection on 06/06/06 for Northfield

This inspection was carried out on 6th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Northfield 22/03/08

Northfield 30/07/07

Northfield 22/02/06

Northfield 12/09/05

Northfield 15/09/04

Northfield 23/04/04

Northfield 29/01/04

Northfield 10/07/03

Northfield 21/01/03

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

CARE HOMES FOR OLDER PEOPLE Northfield 85 George Street Ryde Isle Of Wight PO33 2JE Lead Inspector Annie Kentfield Unannounced Inspection 6th June 2006 11:30 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 Northfield DS0000012517.V292166.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. Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Northfield Address 85 George Street Ryde Isle Of Wight PO33 2JE 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) 01983 562064 01983 562064 Mr Anthony George Kingsley Carlyle Obeyesekere Mrs Pauline Edith Obeyesekere Miss Melanie Jane Paterson Care Home 24 Category(ies) of Dementia - over 65 years of age (5), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (4), Old age, not falling within any other category (21), Physical disability (1), Physical disability over 65 years of age (3) Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. MD/E applies to the current residents only and will cease upon those residents no longer being accommodated at the home. 22nd February 2006 Date of last inspection Brief Description of the Service: Northfield is a care home that provides care and accommodation for 24 older people, including those with a physical disability. The home is a large 3 storey detached property with a ground floor extension. It is located close to the centre of Ryde and within walking distance of the sea front, ferry, rail links and shops. There is off road parking at the front of the home. Access for those with a physical disability or mobility problem is possible as the home has a passenger lift and stair lift to the front door. The passenger lift, however, does not serve those residents accommodated in the ground floor extension. At the rear of the home there is a large conservatory, which leads onto the garden. The current scale of charges is £340 - £360 per week. There are additional charges for chiropody, hairdressing, toiletries, newspapers and transport. Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In order to make an overall judgement on the quality rating for this service information was gathered from a number of sources including an unannounced visit to the home. A second visit to the home was made on 3 July to gather further evidence for the report and provide feedback to the manager about comments that had been received about the service. Seven comment cards were received from relatives and visitors and all expressed satisfaction with the overall care provided. Two visitors commented on the kindness and friendliness of the care staff. Three comment cards were received from health and social care professionals, two of them expressing some concerns about the care provided and these issues have been discussed with the manager of the home for her to investigate. In April of this year a complaint was made about poor practice in the home and alleged neglect of health and personal care needs. The complaint was investigated by the registered owners and also by Social Services as an adult protection issue. Some parts of the complaint were substantiated. The inspector spoke to the complainant who said that they thought that care had improved slightly in the home since then. During the first unannounced visit to the home that took place over six hours, the inspector spoke to some of the service users, some of the staff, and the manager and deputy manager, inspected some of the home’s records, and did a tour of the premises. At the time of the unannounced visit there were seventeen residents, three care staff, manager, chef, and two cleaners. What the service does well: What has improved since the last inspection? Some of the requirements from the previous inspection have been met or work is in progress. Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 6 A lot of work has been done to improve care plans and develop new risk assessments. The manager is working towards ensuring that more than 50 of the care staff have achieved an NVQ level 2 in care by the end of 2006. Decoration work has started in the hallways and should be finished by the end of July 2006. Other maintenance work on the home is planned for 2006/2007. What they could do better: The service is still in the process of meeting some of the requirements from February 2006 and these have been included in this report with the same timescales. The registered manager is aware that further improvements to the service are required and demonstrated a positive attitude and commitment to improving the home for the service users. Although the manager says that she plans to access specialist training for care staff, this has been made a requirement, with a timescale for training and skills in dementia care, mental health care. Some of the requirements relate to the need to improve record keeping in the home, particularly records of induction for new staff and records of service users’ finances. The manager said that staff training has recently been updated in the safe administration of medicines. However, the inspection found that staff are not always following the home’s policies and procedures and it is recommended that the manager introduces regular checks to ensure that staff follow correct procedures at all times and make sure that the medication trolley is always secured as required. The unannounced visit found sufficient staff on duty for the seventeen service users, however, some comments were received that indicated that there have been concerns about staffing levels in the evenings. It is therefore recommended that the manager continue to keep the staffing hours under review to ensure that there are sufficient staff on duty at the busy times of the day to meet the needs of the service users. Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 7 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. Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 8 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 Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 9 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 and 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Since the last inspection there has been one person admitted to the home and records show that the manager requested comprehensive information and a plan of care from the referring care manager before admission was agreed for a temporary period. There is an ongoing programme of training for care staff to ensure that the service can offer the necessary skills and qualifications to meet the assessed care needs of the service users, however, at the moment, there is less than the recommended minimum of 50 of care staff with an NVQ qualification in care of at least level 2. The manager also needs to demonstrate that care staff have specialist knowledge and skills in dementia care and mental health care relevant to the needs of the service users and in line with the home’s stated purpose. Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 10 EVIDENCE: The home does not provide intermediate care but can provide respite care if a room is available. The manager said that they do not take emergency admissions to the home unless all relevant information and a care plan is supplied by the referring care manager, and the manager is confident that care staff can meet all identified care needs. Since the last inspection a lot of work has been done to improve the home’s assessment procedures particularly in the area of assessing and managing any identified risks. This is still a developmental process and further inspection of assessments, care plans, and how the staff identify and manage risk will be reviewed at the next inspection visit. The number of staff working in the home who have achieved the minimum qualification of NVQ level 2 in care has improved although the home do not yet meet the recommended 50 of staff with a care qualification. The manager is in the process of completing training and study in the area of mental health care and is also keen to make sure that relevant information about mental illness and health care is available for staff to read. Specialist training for staff in the areas of dementia care and mental health is planned and when this is achieved the manager can demonstrate that staff have the relevant skills and knowledge to ensure that the assessed needs of the service users will be met and the home is meeting its stated purpose. Northfield DS0000012517.V292166.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Improvements have been made to the way that care plans are set out and there is evidence that service users are more involved in the reviewing of care plans. Care plans should be recording that all identified health and personal care needs are being met, and in most cases this was evident, however, there needs to be greater attention to ensuring that all health care needs are being met where the care plan is complex and involves input from other services. There are policies and procedures for the handling of medication, however, the manager must make regular checks to ensure that staff are following these procedures at all times. Generally, staff were observed to be aware of the need to promote privacy and dignity for service users, however, comments from health and social care professionals show that this does not happen all of the time. Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 12 EVIDENCE: The deputy manager has done a lot of work since the last inspection to make sure that all the risk assessments are clear and up to date. Using an assessment model based on activities of daily living, there is evidence of daily checks to record that all identified care tasks have been carried out. The manager has also updated all care plans. On the whole, this system works well and staff said that they find the system easier to use. The deputy manager also discussed the new risk assessment tool that the home is using and was able to provide evidence of an actual situation where the risk management plan was put into practice. The deputy manager also said that they try to involve the service users in looking at or discussing the care plan wherever possible and, on some care plans, service users had signed the care plan review. There was also evidence that where care needs are more complex, staff had discussed risk management strategies with health care staff. Some of the assessments needed to be signed and dated and in two care plans the moving and handling risk assessment had not yet been completed or a reason given for not doing it. It is also recommended that where a risk management plan records that regular monitoring is required – this should be specific for care staff – stating frequency of checks needed and who has responsibility for doing it. The deputy manager also confirmed that the use of bed rails and other equipment is also discussed with everyone involved in a care plan and where this is the case, it is good practice to ensure that all decisions and discussions are recorded as part of the risk assessment and management plan. The inspector spoke to someone who recently made a complaint about the care provided by the home – the complaint was investigated by the registered providers and manager and also by Social Services. The complainant felt that care practice in the home had since improved slightly. However, comments received from health and social care professionals who visit the home, suggest that good practice in the provision of care is variable. These comments have been discussed with the registered manager who will take action to improve all areas of concern identified. One of the comments made referred to some care staff suggesting that an examination or treatment takes place in the sitting room, rather than in the privacy of a bedroom. The manager explained that staff have been provided with a copy of the social care code of conduct and the home also has a policy Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 13 on privacy and dignity, therefore, action will be taken to ensure that all staff follow this policy at all times. The medication trolley was locked but was not secured to the wall as required. One gap was noted in the medication recording sheets. The manager had a query about the storage of some controlled drugs but following the inspection sought appropriate advice on this. The registered manager must undertake regular checks to ensure that medication is always properly and securely stored and that staff are properly recording all medication. Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 14 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 - 15 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Since the last inspection improvement has been made in meeting service users’ needs for recreational and leisure activities and a member of staff has been given responsibility for organising activities for service users. There has been an improvement in the assessing and managing of risks associated with service users exercising choice and control over their lives. The home’s policy is to offer service users a wholesome and nutritious diet and comments from some service users confirmed that the food in the home is good. EVIDENCE: A new member of staff has been given responsibility for organising a programme of activities for the service users. This is very new and time is needed to develop the project and review its success. The member of staff has spent some time talking to all of the residents about what they would like to do, and this is a positive development that needs to become part of a regular consultation with service users about their choices and preferences in all Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 15 aspects of the care provided. Consideration must also be given to offering service users the opportunity to take part in religious worship if they choose to and the member of staff said that she would investigate this. There is a small budget for activities to purchase games and the services of a musical entertainer. A trip out for tea is planned in the near future. The manager must ensure that there are sufficient staff on duty that are committed to carrying out the daily programme of activities if they are dependent on staff co-ordinating the activity. Activities could also be extended to include Saturdays and Sundays. Some of the residents are able to go out independently, and records show that there are now comprehensive risk assessment and management plans in place that support service users to take reasonable risks as part of their independent lifestyle. Visitors are welcome at any reasonable time and a record is kept of all visitors to the home. Discussion with the chef demonstrated that there is a policy of providing service users with a freshly prepared and nutritious diet. Service users spoken to were very satisfied with the meals provided and it was evident that the chef is able to meet any dietary need or preference. The dining room/sitting room is a large and pleasant room, although some service users choose to take their meals in their room, or in the conservatory sitting room. Care staff were observed to spend time with service users who needed support with eating and the atmosphere was relaxed and informal. Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 16 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, 17 and 19 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. There is evidence that complaints about the home are properly addressed and investigated within agreed timescales. More must be done to ensure that service users’ legal rights are protected, particularly where the manager is an appointee. Staff in the home demonstrated an awareness of the need to protect vulnerable service users. EVIDENCE: A recent complaint about the home was fully investigated and where complaints were substantiated the manager has taken positive action to address those issues. The manager acts as appointee for two service users and records were correct for monies collected and paid on their behalf. However, although receipts have been kept for every purchase, these should be properly recorded so that the accounts can be checked and audited by the registered providers or someone independent, on a regular basis. One service user has amassed considerable income in a current account and this money is not earning interest for the service user, as of right. Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 17 The manager must also demonstrate that where a service user lacks capacity to consent, any large purchases made on behalf of the service user are subject to agreement with the care manager or other representative. The inspector queried the purchase of a pressure mat on behalf of a service user with the service users’ own money; the manager must demonstrate that this purchase has been jointly agreed with the relevant care manager and that such purchases are clearly stated as being the responsibility of service users in the home’s terms and conditions, and statement of purpose. If this is not the case, then the cost must be refunded to the service user. In this case, the manager must ensure that there are proper safeguards in place to protect the interests of this service user and more appropriate financial management and protection must be arranged. It has been confirmed that a care review for this service user is due to take place at the beginning of August and financial management will be reviewed at this time with the community care manager. Records show that new staff have been checked against the POVA (Protection of Vulnerable Adults) list and Criminal Record Bureau checks applied for, before starting work in the home. However, supervision of new staff that are awaiting satisfactory Criminal Record Bureau checks could be more thorough and needs to be properly recorded in the record of induction for new staff. Staff spoken to were aware of the need to protect vulnerable adults and said they would speak to the manager if they had any concerns at all about service users. Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Generally the home is clean and tidy and appeared to be comfortable and homely and meets the needs of the service users. Previous inspections have identified areas of the home that need decoration and maintenance and requirements were made at the last inspection for a programme of decoration and remedial works, some to be completed by 31/07/06 and some to be completed by 31/12/06. Some of these are in the process of being addressed but are not completed. EVIDENCE: At the time of the unannounced visit there were two cleaners in the home and the premises were clean and free from unpleasant odours. The cleaners explained that they have a rota of duties and these are checked off and signed during each shift. Cleaning staff record when a service user chooses not to Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 19 have their room cleaned and this is brought to the attention of the manager to be monitored. Care staff also have areas of responsibility on each shift such as checking that soap and towels are refilled etc. Care staff confirmed that they have access to gloves and aprons as required ensuring they comply with infection control procedures. Work has started on painting the doorframes and skirting and stairwells, as required at the last inspection but this is not finished, however, the manager confirmed that this work would be completed by the end of July 2006. The manager also has a schedule of external work due to take place during 2006/2007. Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 - 30 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. There has been some improvement in this area – more staff have now achieved or are likely to achieve the minimum qualification in care (NVQ level 2). There is a programme of staff training that covers essential areas of health and safety and safe working practice, but the plan also needs to include specialist training in dementia care and mental health care that meets the care needs of the service users in the home. The manager must ensure that new staff are properly supervised and that the induction programme is completed and signed to demonstrate this. EVIDENCE: Some of the comments from service users and relatives particularly mentioned how kind and caring the staff are and this was also observed by the inspector during the inspection visits to the home. In discussion with individual staff; they demonstrated a good awareness of the care needs of the service users. The inspector also observed that staff have a positive and non-judgmental approach to meeting the care needs of service users who present sometimes challenging behaviour due to their dementia or mental illness. Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 21 There are currently seven of the fifteen care staff team who have either the NVQ level 2 or 3 in care and this almost meets the recommended 50 of staff. The manager is in the process of updating the staff training matrix to ensure that all staff have either completed or updated their mandatory training in health and safety and all aspects of safe working practice. Comments from relatives and service users demonstrated a satisfaction with the overall care provided, but some comments from health and social care professionals expressed concern about the lack of consistency in the level of care provided. In discussion with the manager about these concerns, she was positive in her commitment to taking action to address them. Some of the concerns related to sufficient numbers of staff during the afternoon and evening, and the manager said that she keeps the staffing levels under review depending on the number and needs of the service users. Other comments were generally about occasional poor practice or inappropriate behaviour by some members of staff in the home although these comments were not connected with details of specific or recent incidents. However, the manager said that she was very keen to ensure that the home has a good working relationship and communication with all health and social care professionals and would take action to improve practice in the home. Some of the comments suggest that training and supervision needs to be given more attention, and the inspector gave as an example the fact the although the manager has a very comprehensive induction programme in place for new staff, in two cases the induction record had not been completed and signed. New staff that are awaiting confirmation of a satisfactory Criminal Record Bureau check should be regularly supervised during their induction by either the manager or a senior member of staff. The manager plans to arrange training for staff in the areas of dementia care and mental health care and this will further demonstrate that the home is working towards improving practice in the home. Some of the comments received indicate a need for staff to pay greater attention to the detail of care plans and to ensure that they maintain accurate records. Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 22 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, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there has been some improvement in the area of quality assurance since the last inspection of February 2006, there needs to be a more pro-active approach to developing a formal system of quality assurance for the service. There have been improvements to record keeping in the area of care plans and managing risk but better record keeping is required to safeguard some service users’ financial interests. Attention is given to promoting health and safety within the home for staff and service users. Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has the necessary qualifications and experience to run the home and is aware of the areas where improvements are needed and has taken action to address the requirements from the previous inspection. The manager is supported by the registered providers who carry out regular inspections of the home as required by regulation. The manager has recently done some training in managing people and plans to do further training in supervision and recruitment later in the year. A formal questionnaire has been developed as part of the service quality assurance system and a small number have been completed. The manager is aware of the need to provide independent advocacy support for some service users and has taken steps to approach organisations that could provide this. This is a good start in developing the quality assurance for the home and needs to be actively followed up and developed. The manager has recently done some training in fire risk assessment and is in the process of developing a co-ordinated policy of fire safety training for staff, fire practice drills and updating the home’s fire risk assessment. Staff confirmed that they have recently carried out a fire evacuation practice. In discussion, it was agreed that the manager needs to seek advice on the home’s responsibilities for checking compliance with legionalla and temperature checks. There have been improvements to care plans and risk assessments and greater involvement of service users in reviewing care plans. This is very positive and needs to be maintained to ensure that proper records are kept of all care provided. Comment has already been made earlier in this report about the need to improve record keeping and safeguarding procedures for the finances of two service users where the manager acts as appointee. Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 24 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 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 2 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 3 Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 25 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 OP4 Regulation 18 Requirement Timescale for action 31/12/06 2. OP10 3. OP17 4. OP19 The manager must develop staff training in the areas of dementia care and mental health care to meet the needs of the service users in the home. 12 The manager must ensure that all staff in the home provide care in a manner that respects the privacy and dignity of service users. 17 (2) The manager must ensure that and service users’ legal and financial interests are safeguarded at all Schedule 4 times. Regulation All communal areas requiring 23 redecoration, as identified at the last inspection must be completed by the end of July 2006. Doorframes and skirting require repainting Paintwork in the corridors and stairwells require attention. The window frames in the lounge-diner are in need of repair and redecoration. (This is a requirement from 03/07/06 03/07/06 31/07/06 Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 26 5. OP19 the inspection of February 2006 and work is still in progress) Regulation All other areas must be 23 addressed by the end of December 2006. A review of all external aspects of the home undertaken to ensure all remedial works are logged and scheduled for attention. A programme for the redecoration and refurbishment of service users’ accommodation produced and regularly updated. (This is a requirement from the inspection of February 2006 and work is still in progress) Regulation Efforts must be made to ensure 18 the 50 ratio of staff trained to NVQ level 2 and above is achieved by the end of 2006. 31/12/06 6. OP28 31/12/06 7. OP30 8. OP33 (This was a requirement from the inspection of February 2006 and the manager has taken action to meet this in the agreed timescale) 18 New staff working in the home 06/06/06 must follow the home’s induction programme and be supervised during the induction period. Regulation The management must consider 30/09/06 12 how they can formally involve service users within the home’s Quality Auditing programme; and take steps to act upon the decision reached. (This was a requirement from the inspection of February 2006 and work is in progress to meet this requirement but has not been met within the Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 27 9. OP35 17 (2) and Schedule 4 previous timescale of 06/04/06 and a new timescale has been given) The manager must maintain accurate records of service users’ finances and ensure that the registered providers or an independent advisor regularly audits records. 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations The registered manager should ensure that staff follow the home’s policies and procedures for the safe storage and administration of medicines at all times by means of regular checks and monitoring of practice. It is recommended that the manager continue to keep the staffing hours under review to ensure that there are sufficient staff on duty at busy times of the day to meet the needs of the service users. 2. OP27 Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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 Northfield DS0000012517.V292166.R01.S.doc Version 5.2 Page 29 - 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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