Inspection on 29/06/05 for Northfields

This inspection was carried out on 29th June 2005.

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

Northfields 08/05/06

Northfields 16/12/05

Northfields 29/09/04

Similar services:

Pemdale

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

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

CARE HOMES FOR OLDER PEOPLE Northfields 49a Northfields West Earlham Norwich NR4 7ES Lead Inspector Linda Wells Unannounced 29th June 2005 at 13.00 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. Northfields I55 s27527 Northfields v235033 (un) 290605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Northfields Address 49a Northfields West Earlham Norwich Norfolk NR4 7ES 01603 458865 01603 458969 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) Elizabeth Fitzroy Support Mrs Jane Grant Care Home 7 Category(ies) of Learning disability over 65 years of age (7) registration, with number of places Northfields I55 s27527 Northfields v235033 (un) 290605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to seven (7) Service Users who have a learning disability and are over the age of 65 years may be accommodated. 2. The total number of Service Users accommodated not to exceed 7. Date of last inspection 29 September 2004 Brief Description of the Service: Northfields is a detatched, purpose built, chalet style house that is run as a residential care home providing accommodation and care for up to seven older people with learning and physical disabilities. The home is operated as two units within the home, has a shaft lift to the first floor and has seven single bedrooms all containing a washbasin of which one is upstairs and six downstairs. Each unit has a communal lounge, dining room, kitchen, adapted bathroom and toilet and there is a patio area and well kept garden to the rear of the property and parking to the front. The home is sited in the middle of a residential area on the outskirts of the city of Norwich and is near local shops and healthcare facilities. Northfields I55 s27527 Northfields v235033 (un) 290605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken on the 29th June 2005 over three and one half hours and was carried out as part of a routine inspection plan. On the day of inspection the manager was on annual leave and the assistant manager had only been in post for two days. Access to staff files, some servicing records and financial information was not available and will be examined at the next inspection. There were seven residents living at the home and they were seen to be sitting in the lounge watching television or sleeping, taking part in a Karaoke session with a volunteer, in their bedrooms and one was in bed. Conversation was limited for some of the residents and staff members were seen to talk openly with all residents in a warm and respectful manner that promoted choice. The inspection took the form of a tour of the building, individual discussion with three residents, a volunteer and four staff members, observation of three residents, examination of care plans, records, certificates and compliance of requirements and recommendations from the last inspection. What the service does well: What has improved since the last inspection? The home has been made more attractive for those that live there by the redecoration and refurbishment of some bedrooms and some communal areas. The training opportunities for staff have been increased to ensure that residents are well cared for and that staff members are trained in the range of the care needs of each resident. Northfields I55 s27527 Northfields v235033 (un) 290605 Stage 4.doc Version 1.40 Page 6 An assistant manager is now in post to aid the manager in the smooth running of the home, the supervision of staff and to ensure that a high quality of care is provided to the residents. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Northfields I55 s27527 Northfields v235033 (un) 290605 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Northfields I55 s27527 Northfields v235033 (un) 290605 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 3 The written information available about the home is good and enables residents and staff to make a decision on whether the home will meet the needs of anyone wishing to live there. EVIDENCE: Residents have access to the information they need about the home and a Statement of Purpose, Service User Guide and Terms and Conditions contract were seen. However, the Terms of Conditions contract of each resident in the home was stored together in one file and a requirement was made that they be stored in the individual plan of care of each resident to ensure the confidentiality of resident information. Prior to admission to the home an assessment is carried out to ensure that the needs of residents are identified as being able to be met by the home and includes the views of residents, their families and other professionals. Northfields I55 s27527 Northfields v235033 (un) 290605 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 9, 10 The health, personal and social care needs of residents were met, they were well looked after, but records were not fully up to date and all stored in the plan of care. EVIDENCE: Residents did not have their wellbeing fully protected by the records held. Four individual plans of care were examined and found to contain relevant health, personal and social care information, daily records, choice, risk assessments, activities plan, involvement of other professionals and 1st person detail. Although the plan of care contained ‘OK health check’ and ‘Listen to me’ workbooks they were not filled in resulting in incomplete information being held on each resident. Residents had not taken part in regular reviews of the service they had received and there was limited evidence available that they were consulted on their plan of care. Two requirements were made. Resident confidentiality was not assured because information held on all residents was held together in a separate staff memo, a night care, a moving and handling and a behaviour management records file. A requirement has been made that all resident information is held in their individual plan of care. Northfields I55 s27527 Northfields v235033 (un) 290605 Stage 4.doc Version 1.40 Page 10 Residents were not fully protected by the medication records held in the home because there were two gaps in the records. Although staff had undertaken training and there were adequate policies and procedures in place they had not been fully followed and a repeated requirement from the last inspection was made that complete medication records are held. Those that lived at the home were treated with respect and the three residents spoken to all said that staff members protected their privacy when they were assisted with personal care. Northfields I55 s27527 Northfields v235033 (un) 290605 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 14, 15 Social activities and meals are both planned, creative and provide daily variation and interest for the people living in the home. EVIDENCE: Residents are stimulated by the program of activities and records were seen to demonstrate that some residents attend a local training centre, take part in leisure activities and outings such as going to the pub, shopping, attend local community events such as the theatre and are taken on holiday by staff. Two of the residents spoken to said that staff helped them to choose what they did in their spare time and one gave an example of being taken out each week to play bingo and the other spoke of the holiday he had been on. The staff spoken to gave examples of how they support residents in making a choice and to reach their potential and all said that the program of activities and leisure pursuits were determined by the interests and personal development plan of each resident. A snack meal and menus were seen and were balanced and varied. Records showed that residents were given choice and an alternative offered. Northfields I55 s27527 Northfields v235033 (un) 290605 Stage 4.doc Version 1.40 Page 12 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 and 18 The home’s complaints procedure is good, offers protection to residents and supports the investigation of any cause for concern. EVIDENCE: No complaints have been received by the home since the last inspection and the residents spoken to all said that if they were unhappy they would tell their key worker or the manager and all agreed that they would be listened to and the appropriate action taken to resolve the problem to the satisfaction of all concerned. Residents are protected from abuse, neglect and self-harm by the objectives, policies and procedures of the home and staff have undertaken training in Adult Abuse to help them recognise, prevent and deal with any potential abuse. Northfields I55 s27527 Northfields v235033 (un) 290605 Stage 4.doc Version 1.40 Page 13 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, 21, 24, 26 Recent improvements have been made to parts of the home but there are remaining areas that require attention to make the surroundings more attractive for those living and working in the home. EVIDENCE: A tour of the building revealed that the home was mainly clean, odour free, homely and furnished and decorated to a good standard in some areas. The exception was the carpets throughout the home that were stained and dirty, the slight odour of urine that was in one bedroom and the need to continue the redecoration of some bedrooms in the home and the hallways, lounge and dining room in one unit. Two requirements were made that the carpets in the home be replaced or deep cleaned and the bedroom thoroughly cleaned and the carpet replaced. A recommendation was made that the remainder of the home is redecorated. The home has sufficient and suitable toilet and washing facilities and residents had personalised their bedrooms. All infection control measures were in place and the laundry room contained a service washing machine and tumble dryer Northfields I55 s27527 Northfields v235033 (un) 290605 Stage 4.doc Version 1.40 Page 14 and sluicing facilities to aid in the protection of the health and safety of all residents and staff. Northfields I55 s27527 Northfields v235033 (un) 290605 Stage 4.doc Version 1.40 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) 28 and 30 Staff members are competent and have undertaken training but not all staff members had completed basic training. EVIDENCE: Staff members are aware of the needs of each resident and their role and responsibilities. The four staff members spoken to said that they felt supported by the manager, the daily handover, received supervision and attended staff meetings to ensure the protection of those living at the home. The staff spoke of completing induction and foundation, communication, challenging behaviour, food hygiene and NVQ2 training but one relief staff member who worked regularly in the home and had been employed since September 2004 had not completed moving and handling training and although she had been shown how to move and handle residents at the home by other staff a requirement was made that she complete this training. The staff files and full training records were not available and will be examined at the next inspection. Northfields I55 s27527 Northfields v235033 (un) 290605 Stage 4.doc Version 1.40 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) 32, 33, 37, 38, The home is well run and the manager provides leadership, guidance and direction to staff to ensure that the residents receive a good standard of care. EVIDENCE: Residents and staff said that the manager was friendly, had an open approach, encouraged teamwork and used her leadership skills to promote and maintain high standards of care. Residents and the staff spoken to said that the home was run in a way that promoted the best interests of those that live there. The storage of resident information resulted in the confidentiality of records not being fully assured for residents and three requirements have been made that have been dealt with in standards two and seven. The health, safety and welfare of residents is promoted and protected and the servicing and testing of equipment in the home had been carried out and relevant and timely certificates were held. Northfields I55 s27527 Northfields v235033 (un) 290605 Stage 4.doc Version 1.40 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 x 2 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 2 x 3 x x 3 x 2 STAFFING Standard No Score 27 x 28 3 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 3 x x x 2 3 Northfields I55 s27527 Northfields v235033 (un) 290605 Stage 4.doc Version 1.40 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 OP2 Regulation 17.2 Requirement The registered person must ensure that the Terms and Conditions contact of each resident is stored in their individual plan of care. The registered person must ensure that complete health and social care information is held on each resident. The registered person must ensure that the information held on each resident is stored in their individual plan of care. The registered person must ensure that a review of the care provided is undertaken with the resident on a regular basis. The registered person must ensure that medication administration records are complete. REPEATED The registered person must ensure that the carpets in the home are deep cleaned or replaced. The registered person must ensure that all rooms in the home are free of offensive odours. The registered person must ensure that all staff working in Timescale for action 1st September 2005 30th September 2005 30th September 2005 31st August 2005 and ongoing 1st August 2005 and ongoing 31st October 2005 1st August 2005 and ongoing. 31st August 2005 and Page 19 2. OP7 12.1.a 3. OP7 17.1 schedule 3 15.2.b 4. OP7 5. OP9 17.1.a schedule 3.3.i 23.2.d 6. OP19 7. OP26 16.2.j 8. OP30 18.1. c.i Northfields I55 s27527 Northfields v235033 (un) 290605 Stage 4.doc Version 1.40 the home have undertaken training in moving and handling. ongoing 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 OP19 Good Practice Recommendations It is recommended that the redecoration of the home continues. Northfields I55 s27527 Northfields v235033 (un) 290605 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection 3rd Floor - Cavell House St Crispins Road Norwich NR3 1YF 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 Northfields I55 s27527 Northfields v235033 (un) 290605 Stage 4.doc Version 1.40 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!