Inspection on 01/03/05 for Northfield Nursing Home

Care Home For Older PeopleNorthfield Nursing Home2a Roebuck Road Sheffield South Yorkshire S6 3GPUnannounced Inspection1st March 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Northfield Nursing Home Address 2a Roebuck Road, Sheffield, South Yorkshire, S6 3GP Email address Name of registered provider(s)/company (if applicable) Palms Row Health Care Name of registered manager (if applicable) Lynne Neil (currently undergoing registration) Type of registration Care Home No. of places registered (if applicable) 63 Tel No: 0114 268 7827 Fax No: 0114 267 9591Category(ies) of registration, with (number of places) Old age, not falling within any other category (63) Registration number J550002014 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 10th May 2004 YES YES 2/08/05 If Yes refer to Part CNorthfield Nursing HomePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 31st march 2005 09:30 am ­ 4:00 pm Carol Ann Makin Janis RobinsonID Code073015 088676Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionN/A Lynne Neil, manager.Northfield Nursing HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementNorthfield Nursing HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Northfield Nursing Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Northfield Nursing HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Northfield is a care home providing personal and nursing care. Accommodation is provided for 63 service users. The home is owned by Palms Row Health Care and is situated in the residential area of Crookesmoor. It is close to the main bus route and is a short walk away from the Upperthorpe shopping area. The home is purpose built with accommodation provided on two floors, which are accessed, by a lift. The home provides nursing and personal care, service users accommodation is provided in 49 single rooms and 7 shared. There is a garden area that is safe and private for service users to enjoy. The grounds are accessible and well laid out, the garden sitting areas are attractive and well maintained.Northfield Nursing HomePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY This unannounced inspection took place over one day. The manager, staff and service users were supportive of the inspection process. The focus of this inspection was to check those requirements made at the announced inspection of 2/08/04, and any key standards not assessed during the last announced inspection. All of the staff, service users and visitors spoken with during the inspection commented that improvements to the home had taken place. The manager evidenced that she had undertaken audits, prioritised and identified action for improvements. Choice of Home. Standards 1 to 6. The homes service user guide had been updated to include information on how to access the homes last inspection report. The guide required further update to include the names of the new manger and cook. Health and Personal Care. Standards 7 to 11. The homes care plans had been identified as containing various gaps, and required completing in full. The service users and visitors spoken with commented that care needs were well met. Staff were observed knocking on service users doors before entering. Service users commented that staff were respectful. Daily Life and Social Activities. Standards 12 to 15. An audit had been undertaken to determine the staff response to call buzzers. Some service users stated that this was still a problem in the home. The service users and visitors spoken with were aware of individual care plans, and stated that they had been involved in these. All of the service users stated that the food had greatly improved at the home. Complaints and Protection. Standards 16 to 18. The home had a complaints procedure, and each service user had been provided with a copy. Service users and staff stated that they would feel able to complain. The home had an Adult Protection procedure. Some staff required training in adult protection. Environment. Standards 19 to 26. On the day of the inspection the home was clean and free from odours. Communal areas were well maintained and appeared comfortable. Service users bedrooms were well personalised. A minority of bedrooms seen had slightly damaged decoration, records needed completing regarding the provision of bedside lighting and two chairs. One bedroom door was sticking and difficult to open/close. Some bedroom furniture was beginning to show signs of age. Fluorescent lighting was provided in corridors. Not all bedroom doors were provided with locks. Some bathrooms were still used to store equipment. One bathroom was dirty. Staffing. Standards 27 to 31. The homes rotas were checked for the week of the inspection. These did not fully record the numbers of staff provided at the home, and did not reflect the Northfield Nursing Home Page 6 numbers actually on duty. Staff confirmed that agreed levels of staff were being maintained. A proportion of staff were undertaking National Vocational Qualifications (NVQ) in care, however, the home falls below the 50 of care staff required to achieve this qualification. The home had a staff training plan. Management and Administration. Standards 32 to 38. Since the last inspection a new manager had been employed at the home. All staff stated that she was approachable and supportive. The inspectors evidenced that relevant audits had been undertaken, and appropriate development prioritised and identified. Staff meetings were not held on a regular basis. Not all notifiable incidents had been reported to the Commission for Social Care Inspection (CSCI). Staff did not receive formal supervision. The homes records of fire drills evidenced that insufficient information had been recorded. Staff mandatory training required auditing and any identified training provided. A staff training matrix was not in place. Hoists were charged on corridors, which could pose a tripping hazard.Northfield Nursing HomePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 2 12 12 OP12 OP12 Assistance must be given to service users who wish to sit outside when the weather permits. The manager must undertake further unannounced audits of response times to call systems at varying times of the day. If service users needs are high then the staffing levels must be increased to reflect these needs. All staff must receive training on adult protection issues. Light fittings must be domestic in design. Bathrooms must not be used, as storage areas for aids and equipment and a suitable safe area must be provided for the hoists that need to be electrically recharged. A lockable facility must be provided in all service users rooms. Service users bedrooms must be fitted with locks. They must be of a type that can be opened from outside in emergencies. Assessments must be carried out to ensure that service users who want/need seating for 2 people, and/or bedside lighting, are provided with them. This must be recorded in their files. How ventilation is safely provided in the identified service users room without opening windows must be demonstrated. 31st May 2005 31st May 20053 4 513 23 23OP18 OP20 OP2231st May 2005 31st May 2005 31st May 20056 723 23OP24 OP2431st May 2005 31st May 2005 31st May 2005823OP24923OP2531st May 2005Northfield Nursing HomePage 8 1021OP33An annual development plan for the home must be produced taking into account the findings of the quality assurance surveys.31st May 20051118OP36All staff must receive supervision at least six 31st May times a year that covers all aspects of care, 2005 philosophy of care in the home and their career development needs. Records required by regulation for the protection of service users must be maintained, up to date and accurate. All accidents, injuries and incidents of illness or communicable diseases must be reported to the CSCI. 31st May 2005 31st May 20051217OP371337OP38RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 2 OP28 OP31 A ratio of 50 of all care staff must be qualified to NVQ level 2 or equivalent by 2005. The manager should ensure she has a management qualification equivalent to NVQ level 4 by 2005.CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). NoneMet (Yes / No)Northfield Nursing HomePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 5 OP1 The homes service user guide must be updated to include the names of the current manager and cook. 31st May 2005215OP7Action must be taken, as identified in the homes care plan audit, to ensure all individual 31st May plans are accurate and up to date. 2005 Care plans must be completed in full.312OP10The homes pay phone must be fully accessible to service users. A chair must be provided. The manager must consult with service users to ensure choices regarding meals and snacks offered meet needs, with particular reference to suppertime. Bathrooms and toilets used independently by service users must be monitored to ensure they are kept clean.31st May 2005416OP1531st May 2005523OP2131st May 2005623OP24An audit of bedroom decorations must take place, and any identified damage included in 31st May the homes redecoration programme. The two 2005 identified bedrooms must be redecorated.Northfield Nursing HomePage 10 723OP24An audit of bedroom furniture must take place. Where furniture is showing signs of age, this must be identified within the homes refurbishment programme for replacement.31st May 2005823OP24The identified bedroom door must be repaired 31st April to ensure it opens and closes easily. 2005 The staff rota must fully and accurately reflect 31st May the names and numbers of staff on duty. This 2005 must include agency staff. Regular staff meetings must be held, and records kept. The monthly visits to the home undertaken by the responsible individual must be unannounced. An audit of staff mandatory training must take place, records must be kept. Any identified training must be provided. All staff must undertake training in food hygiene. An audit of staff participation in fire drills must take place. Any identified staff must participate in a drill. Records of staff training must be organised and accessible, to ensure accurate information and relevant training is provided. Records of fire drills must state the full names of the staff participating. 31st May 2005 31st May 2005 31st May 2005 31st May 2005 31st May 2005 31st May 2005 31st May 2005912OP271018OP321112OP331213OP381318OP381413OP381512OP381613OP38RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * See previous recommendations.Northfield Nursing HomePage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NA YES YES NO NO NO YES YES YES YES YES YES NA NA NA YES YES YES 6 3 X NO NO YES YES 37 8 1/03/05 9:30 13Northfield Nursing HomePage 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Northfield Nursing HomePage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) X To (£) XAny charges for extrasNOIf yes, please state what the extras are: 2 Key findings/Evidence Standard met? This standard was fully assessed at the last inspection. A requirement was made to ensure information was included in the service user guide informing how to access the homes latest inspection report. The inspectors evidenced that the guide had been updated. The names of the previous manager and cook were included in the guide, which needed updating.Northfield Nursing HomePage 14 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 0 Key findings/Evidence Standard met? This standard was assessed and met at the last inspection.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? This standard was assessed and met at the last inspection.Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? This standard was assessed and met at the last inspection.Northfield Nursing HomePage 15 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? The home did not offer intermediate care.Northfield Nursing HomePage 16 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 2 Key findings/Evidence Standard met? Each service user had an individual plan of care. A requirement was made at the last inspection to ensure that service users were involved in their plan of care, should they wish. Service users and their relatives spoken with knew of their right to see their files. The manager had undertaken an audit of care plans, which the inspectors examined. This indicated that the majority of plans did not contain all of the required information, and were not completed in full. Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) X X3 Key findings/Evidence Standard met? A requirement was made at the last inspection to investigate why a minority of service users felt their care needs were not well met. The manager had undertaken a recent quality assurance audit, which included meeting care needs. All of the service users spoken with stated that their care needs were well met. Each of the three visitors spoken with stated that they felt their relatives care needs were well met, and they were kept fully informed of their relatives health by staff at the home. Service users and relatives reported that care had improved since the new manager had been in post.Northfield Nursing HomePage 17 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 0 Key findings/Evidence Standard Met? This standard was assessed and met at the last inspection.Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 2 Key findings/Evidence Standard met? A requirement was made at the last inspection to ensure staff treated service users with respect at all times and must knock on bedroom doors before entering. The inspectors observed this practice on the day of the inspection. All of the service users and staff spoken with stated that staff treated them with respect. The inspectors evidenced that whilst the home had provided a payphone in a private location for service users, no chair was provided and the phone was situated behind a door, which could pose a problem in terms of independent access.Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? This standard was assessed and met at the last inspection.Northfield Nursing HomePage 18 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 2 Key findings/Evidence Standard met? Two requirements were made at the last inspection in relation to this standard. Concerns had been raised by service users regarding the response to call buzzers. A proportion of service users spoken with stated that they still had to wait some time for staff to respond. One service user stated that they had to wait up to thirty minutes on some occasions. This requirement has been carried forward. A further requirement to ensure assistance is given to service users who wish to sit outside when the weather permits has been carried forward and will be assessed at the next inspection. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 0 Key findings/Evidence Standard met? This standard was assessed and met at the last inspection.Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? A previous requirement was made in relation to ensuring service users were fully involved in their care plan, and were aware of their rights to read what was written about them. All of the service users and relatives spoken with stated that they had been informed of their rights.Northfield Nursing HomePage 19 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 2 Key findings/Evidence Standard met? A requirement was made at the last inspection to ensure the quality of food provided at the home was improved. Since the last inspection a new cook had been employed. All of the service users, staff and relatives spoken with stated that the quality of food provided had vastly improved. Service users said that they enjoyed the meals provided, and choices were offered. Two service users told the inspectors that nothing was offered at suppertimes.Northfield Nursing HomePage 20 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X X X 3 Key findings/Evidence Standard met? A requirement was made at the last inspection to ensure all service users were informed of the homes complaints procedure, and felt able to complain should the need arise. All of the service users spoken with stated that they knew how to make a complaint. All service users, staff and relatives stated that they had confidence in the homes manager to respond and deal with any complaints. The homes quality assurance audit indicated that the majority of service users and their relatives knew how to complain. A minority of relatives stated that the service users would not know how to complain, due to confusion, but they would undertake this on the service users behalf. The incidence of complaints about the home to the CSCI has reduced. This is a reflection of the improvement to the home reported by staff, service users and relatives.Northfield Nursing HomePage 21 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES X2 Key findings/Evidence Standard met? A requirement was made at the last inspection to ensure that all staff had undertaken Adult Protection training. This training had been provided to staff working at the home at that time. However, this training needed to be provided to staff that had commenced employment at the home since the training took place. Therefore the requirement has been carried forward.Northfield Nursing HomePage 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? This standard was assessed and met at the last inspection.Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 2 Key findings/Evidence Standard met? A requirement was made at the last inspection to provide domestic style lighting in corridor areas. This requirement has been carried forward. The home did have an appropriate amount of sitting, recreational and dining space. There were sufficient rooms for a variety of activities to take place. Service users could see visitors in private in their own rooms. This was a non-smoking home however a shelter had been provided outside for anyone who wished to smoke. Outdoor space and all areas of the home were accessible to people in wheelchairs. Furnishings and fittings were domestic in design and in good condition.Northfield Nursing HomePage 23 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 2 Key findings/Evidence Standard met? The home did have a sufficient number of baths, showers and toilets. These were close to bedrooms, lounges and dining areas and doors were labelled. A requirement was made at the last inspection to ensure locks to bathrooms and toilets were in working order. This had been actioned. One toilet was dirty. The manager stated that some service users independently accessed the toilet. Systems must be put in place to ensure cleanliness is monitored and maintained. Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 2 Key findings/Evidence Standard met? A previous requirement that bathrooms must not be used to store aids and equipment and that a safe area must be provided for hoists had not been actioned. The hoists were stored on the corridors to enable batteries to be recharged. Some bathrooms were used to store aids. These requirements have been carried forward.Northfield Nursing HomePage 24 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO NO YES X X X X 0 X XX X X XKey findings/Evidence Standard met? This standard was assessed and met at the last inspection.Northfield Nursing HomePage 25 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 2 Key findings/Evidence Standard met? All of the bedrooms seen by the inspectors were comfortable and well personalised. A requirement was made at the last inspection to provide locks to all bedroom doors. This has been carried forward. A further requirement was made to evidence in records that service users had been offered a bedside light and two chairs. The homes care plan audit evidenced that this had not been completed. This requirement is carried forward. One bedroom door was sticking. This was difficult to open. Two bedrooms had slightly damaged decoration. The homes quality assurance survey indicated that some bedroom furniture was showing signs of age. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 2 Key findings/Evidence Standard met? One service users bedroom did not have an opening window for ventilation, there was an external door that was signed an exit door. A requirement was made in relation to this issue to explore ways in which ventilation could be provided. This requirement has been carried forward.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 0 Key findings/Evidence Standard met? This standard was assessed and met at the last inspection.Northfield Nursing HomePage 26 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X8 37 X2 Key findings/Evidence Standard met? The homes rota for the week of the inspection was examined. This evidenced the names and numbers of the permanent staff on duty. The rota also indicated the requests for agency staff, to ensure numbers of staff were maintained. The rota did not accurately and fully reflect the number of staff on duty. All of the staff spoken with confirmed that agreed levels of staff were being maintained.Northfield Nursing HomePage 27 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 0 0 1 Key findings/Evidence Standard met? 3 care staff were undertaking NVQ level 2 in care. Further staff had expressed an interest in undertaking the training. A previous recommendation made in relation to this issue has been carried forward.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This standard was assessed and met at the last inspection.Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection. Issues related to staff training are reported on in the relevant sections of this report.Northfield Nursing HomePage 28 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 2 Key findings/Evidence Standard met? Since the last inspection a new manager had been employed by the home. She is a qualified nurse and intended to undertake NVQ level 4 in management and care. The manager was applying for registration at the time of this inspection.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 2 Key findings/Evidence Standard met? All of the service users, staff and relatives spoken with reported an improvement to the home since the manager had been employed. Staff stated that morale had improved. Service users and staff said the manager was approachable and supportive. Regular staff meetings were not held.Northfield Nursing HomePage 29 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 2 Key findings/Evidence Standard met? Since the last inspection the homes service user guide had been updated to include information on how to access the homes last inspection report. The new manager had undertaken a thorough quality assurance questionnaire. The results of the survey had been published and were kept in the reception area for service users and visitors. The publication included positive feedback and areas identified for improvement. This is to be commended. The manager had undertaken audits of systems and identified action required. The manager must ensure that systems are put into place to ensure identified action is prioritised and undertaken. An annual development plan had not been produced. A previous requirement made in relation to this issue has been carried forward. Whilst the manager confirmed that monthly visits by the responsible individual took place, these were not always on an unannounced basis. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? This standard was assessed and met at the last inspection.Northfield Nursing HomePage 30 Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence This standard was not assessed during this inspection. Standard met? 0 X X XStandard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 1 Key findings/Evidence Standard met? Formal staff supervision did not take place. The manager was implementing staff appraisals. A discussion took place regarding the requirement for staff supervision. A previous requirement made in relation to this issue has been carried forward.Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met? The inspectors checked a sample of the records that the home is required to keep. Specific omissions have been identified throughout this report and requirements made. The requirement relating to the records is carried forward.Northfield Nursing HomePage 31 Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? The home had a health and safety policy. On the day of the inspection fire exits were clear. The manager stated that systems were checked and serviced. Staff interviewed confirmed that they had undertaken relevant mandatory training. However, one member of staff had not undertaken food hygiene refresher training, as required. Staff fire training records were difficult to navigate and monitor. A staff training matrix was not in place, resulting in staff training being difficult to monitor. Staff fire drill training did not always record the full names and designation of the staff participating. Records checked confirmed that not all notifiable incidents were being reported to the CSCI as required. A previous requirement made in relation to this issue has been carried forward.Northfield Nursing HomePage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSYES Condition Compliance One specific named service user is under the age of 65 years and can remain at the home. Comments The service user is deceased.Lead Inspector Second Inspector Locality Manager DateJanis Robinson Carol Makin Amanda Lindley 1.03.05Signature Signature SignaturePublic reports It should be noted that all CSCI inspection reports are public documents.Northfield Nursing HomePage 33 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 1/03/05 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleNorthfield Nursing HomePage 34 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan within 28 days, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YES D.2Action plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NONorthfield Nursing HomePage 35 D.3PROVIDERS AGREEMENT unannounced Inspection 1/03/05 Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Julian Kendall of Northfield confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I Julian Kendall of Northfield am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Northfield Nursing HomePage 36 Northfield Nursing Home / 1st March 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000021798.V145024.R01© This report may only be used in its entirety. 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