Inspection on 19/06/07 for Northgate House

This inspection was carried out on 19th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Northgate House 19/05/09

Northgate House 16/06/08

Northgate House 13/06/06

Northgate House 06/03/06

Northgate House 09/12/04

Northgate House 26/08/04

Northgate House 27/02/04

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Hawkhills

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Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Northgate House 92 York Road Market Weighton York East Yorkshire YO43 3EF Lead Inspector Mr M. A. Tomlinson Unannounced Inspection 19th June 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Northgate House DS0000019701.V339712.R02.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. Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Northgate House Address 92 York Road Market Weighton York East Yorkshire YO43 3EF 01430 873398 01430 871706 northgatehouse@supanet.com 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) Mr John Keith Chambers Mrs Jean Chambers, Miss Elizabeth Joy Chambers Position Vacant Mrs Jean Chambers Care Home 25 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (25) of places Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th June 2006 Brief Description of the Service: Northgate House is registered to provide residential, personal, and social care for 25 people over the age of 65 years, including people with dementia. The home is a large house that has been extended to meet the demand of a growing local population. There is a well-tended garden and patio area located at the rear of the premises that provides a safe and secure area for the residents walk around, sit, or enjoy activities. There is a car park for staff and visitors. All areas of the building are accessible to service users via the use of ramps and a stair lift. The home is located close to the centre of Market Weighton and provides good access to the town’s services and amenities. The home was first registered in 1984 and was acquired by the present owners in September 1998. The registered providers are Mr and Mrs Chambers and their daughter Miss Joy Chambers. Currently there is no registered manager in post and Mr and Mrs Chambers, who previously undertook this role, are again overseeing the running of the home themselves. The home has an information pack and service user guide to inform prospective residents about the home. The fees for the home ranged from £334 to £480. Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit formed an integral part of the annual ‘key inspection’ process for the home undertaken by the Commission for Social Care Inspection (CSCI). Information contained in this report was obtained through discussions with the home’s registered provider/manager, the staff on duty at the time of the visit, a number of residents and the relatives of two residents. Since the previous inspection visit the registered manager has resigned from his post and consequently the registered provider is acting in that capacity in the interim and until and management situation is resolved. Reliance was also placed on observation of the staff and the support provided for the less able residents. The report incorporates information provided by the registered provider in the pre-inspection questionnaire. In addition the report includes relevant information obtained by the CSCI prior to, and subsequent to, the inspection visit. A number of statutory records kept by the home were also examined and an inspection of the premises carried out. What the service does well: What has improved since the last inspection? Due to the recent internal staff and management problems in the home, there has been little opportunity for improvement since the last inspection. The registered providers are very aware of this and are consequently taking action to address any shortfalls in the service that have been identified by them since the resignation of the registered manager. Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 6 What they could do better: The registered providers have identified several areas in the service that require improvement and are in the process of addressing them. These include: • A major programme of refurbishment that includes a partial rebuild of the property. It is intended that this will improve the residents’ private accommodation, provide facilities for staff and will include the installation of a passenger lift thereby enabling the residents to have access to all parts of the home. A review of all of the home’s records, policies and procedures is underway. This includes revising the residents care plans, reintroducing staff supervision and appraisal and developing the staff training programme. It is the intention of the registered providers to apply to the CSCI to have three managers jointly registered so that there will be a management presence on each day of the week. Two of the registered managers will be responsible for the standard of the care provision whilst the third will manage business aspects of the home. The registered provider was reminded of the need for prospective staff to be fully vetted before taking up a post in the home and that the use of POVAFirst arrangements should only be used in exceptional circumstances. Whilst staffing levels may satisfy the recommended minimum the day staffing level needs to be kept under review to ensure that it satisfies not only the residents’ physical needs but also their emotional and social needs. It is suggested that greater emphasis is placed on providing residents with more ‘quality’ or one-to-one time in order to provide a greater level of stimulation for them. • • • • Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Prospective residents are provided with adequate information on which they could make a considered decision as to whether or not they wished to be admitted into Northgate House. People who use the service experience good quality outcomes in this area. EVIDENCE: The home had an appropriate admission policy and procedure. The Registered Provider stated that she carried out the pre-admission assessments on prospective residents who were not placed by a local authority. These assessments were available in the residents’ care records. They were reasonably comprehensive and enabled a considered decision to be made as to whether the staff of Northgate House were able to meet a person’s needs. Reliance was placed on the assessment provided by the respective local Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 9 authority if a resident was publicly funded. Several of the residents and their relatives confirmed that they visited the home prior to making a decision for the prospective resident to be admitted. A number of the residents had previously lived locally and had made a decision to live at Northgate House because of its location. Prospective residents had been sent an information pack, that included the Service Users’ Guide so that they had adequate information on the home, its facilities and the service provided in order to assist them in making a decision regarding admission. It was noted, however, that they were not sent a letter confirming that the home was able to meet their assessed needs. The residents’ care records provided recorded evidence that they had been provided with a contract that included the terms and conditions of their residence. This contract was not finalised until the completion of a four-week trial period to ensure that both the home and the resident concerned were happy with the placement. Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Once the revised care plans have been completed and the relevant information transferred from existing records, the staff should have access to sufficient information on the residents which will enable them to deliver good standards of care. People who use the service experience good quality outcomes in this area. EVIDENCE: The care records of three residents were examined. They all contained a personalised care plan that identified the primary aims of the resident concerned and the action required by the staff in order to meet those needs. The care plan developed by the home was in addition to any care plan implemented by the resident’s placing authority. At the time of the inspection visit the care records and the care plans were in the process of being revamped in order to make them easier to use by the staff. The care plans were broken into elements of care covering a resident’s Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 11 physical, social and emotional needs. Included with the care plans was a range of individual risk assessments and a personal profile of the resident concerned. Some of the information had yet to be transferred from the original care records into the new ones. This had caused some confusion for the staff. For example, the staff were unsure if there was a risk assessment for a resident who had bedrails fitted. It was apparent from discussions with the staff that reliance was placed on their personal knowledge of the residents to address those needs that had not been formally included in the respective care plan. There was also no clear evidence of the action taken to address the needs identified in the care plans. When asked how the staff know that the residents’ needs have been met, a senior member of care staff responded, “Because we do”. During this transitional stage it was difficult to audit the care records and carryout a case tracking process. The records confirmed that the care plans had been regularly reviewed with the resident or their representative signing the amended care plan in agreement. The residents had an allocated Key Worker who was responsible for monitoring their health and welfare and reviewing the care plans monthly. The care staff spoken to had a good understanding of their responsibilities as a key worker and confirmed that they were expected to spend time with their allocated residents on a one-to-one basis. It was observed that when the residents were being provided with a cup of tea in the afternoon, the care staff held the cup by the rim with their fingers. The residents were also handed a biscuit by the staff from a large biscuit barrel. These practices could be seen as being unhygienic and could undermined the residents’ dignity. The registered provider said that the care staff had been instructed to put the biscuits on a plate and allow the residents to choose which should overcome any potential problems. It was evident from the records that there had been good levels of input from health and social care professionals. District and community nurses generally visited the home twice each day to provide nursing care for specific residents. Nursing notes were available in the home. The home had a general practitioner (G.P.) allocated by the local medical practice. It was evident that a good relationship had been established with this G.P. who held a surgery once a week in the home. One resident who had been accommodated for a considerable time in the home spent most of her time in her room with the District Nurse visiting her regularly. Following the requirement made during the previous inspection the medication administration process had been reviewed and revised to ensure it was safe and efficient. The home continued to use a Monitored Dosage System for the bulk of the residents’ medication with the remaining medication being administered directly from their original containers. The ‘in-use’ medication was stored in a lockable drugs trolley that was appropriately secured when not in use. Medication stock and controlled drugs were secured in appropriate Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 12 cabinets located in a locked room. Evidence was available to confirm that the staff had been trained in the safe handling of medication. The medication records were complete and up to date. It was observed that the medication was administered directly to the resident concerned and signed for by the staff at the point of administration. From a description of the medication administration process provided by a member of staff, it was concluded that all reasonable steps had been taken to eliminate the possibility of error. Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Whilst the residents are provided with opportunities to participate in group activities it was felt that increased ‘quality’ or one-to-one time should be spent by the staff in meeting the residents’ individual social and emotional needs. People who use the service experience adequate quality outcomes in this area. EVIDENCE: From discussions with the staff, the more able residents and an examination of the records, it was apparent that the residents are provided with the opportunity to participate in a range of social activities both within and outside of the home. The majority of these activities were, however, undertaken on a group basis and there was only limited evidence of residents being provided with activities on a one-to-one basis. The registered provider stated that they took a flexible approach to social activities to take into account, for example, the residents’ wishes and the weather. Some staff surveys suggested that insufficient time was available to provide activities. But the residents spoken Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 14 to said that boredom was not a problem and the majority looked reasonably stimulated. The relatives of the residents were encouraged to visit the home and take the respective resident out. Visiting relatives provided examples of this. The relative of one resident stated, “ What I like about this place is the bubbly and happy atmosphere”. It was observed that the care staff took the opportunity to engage several residents in an indoor game. Some of the more able residents went out unaccompanied. The staff confirmed that regular visits to the home were made by representatives of local churches in order to meet the residents’ religious needs. The residents confirmed this. One of the assistant managers had been delegated the task of organising activities for the residents. This member of staff provided examples of how they were intending to develop the activity programme. The home had two qualified and experienced cooks who had the responsibility for providing the meals on each day of the week. From discussions with one of the cooks it was apparent that they had a good understanding of the dietary needs of older people. The menus indicated that the residents were provided with a varied and nutritious diet. For example, full fat milk was used for the majority of the residents. It was evident that emphasis was placed on the use of fresh vegetables and meat. The daily menu was displayed in the entrance area. The lunch menu offered a vegetarian alternative. Those residents spoken commended the quality of the meals. Some of the staff surveys stated that the residents did not have enough genuine choice and that the meals did not always take into account difficulties with eating. There was recorded evidence, however, that the residents chose their breakfast in advance from a relatively wide-ranging menu. The care records confirmed that a nutritional assessment had been undertaken on the residents and provided that they were weight-bearing they were regularly weighed as part of nutritional monitoring process. The home did not have appropriate weighing scales for use by people who were not weight bearing. The residents were provided with a choice of dining area or they could have their meals in the their room if they so wished. Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The residents are protected through the availability of an acceptable complaints procedure and staff training in safeguarding adults. People who use the service experience good quality outcomes in this area. EVIDENCE: The home had an appropriate complaints procedure that was included in the Service Users’ Guide. Prospective service users had been provided with a copy of the complaints procedure and a further copy was available in their rooms. Those residents spoken to could not envisage using the complaints procedure but they felt confident that they could talk to the staff regarding any concerns they may have. The relatives of residents spoken to were aware of the complaints procedure and felt confident that they would use it if necessary. One relative stated, “If I was not happy I’d certainly complain”. The staff had received training in adult protection (safeguarding) adults’ procedures. This had included training on the types and indications of abuse. A survey from a social services’ care coordinator indicated their satisfaction with the care and protection provided for the residents. Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26 People who use the service live in a clean, well maintained environment whiich generally meets their needs and prefrences and which will be greatly improved on the completion of the refurbishment plan. People who use the service experience good quality outcomes in this area. EVIDENCE: The premises continued to be maintained and decorated to a good standard. The home had the services of maintenance person who undertook regular safety checks of the home and ensured that repairs were readily addressed. According to visitors to the home the cleanliness of the premises had noticeably improved since the registered providers had employed an outside Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 17 cleaning agency. The residents confirmed that their rooms were cleaned daily. All areas of the home inspected were clean, hygienic and free from offensive smells. It was observed that the staff had disposable protective clothing available. The home was furnished to a good standard with furniture that met the needs of the residents. The residents said that they liked their accommodation and found it homely and comfortable. It was evident that the residents had been encouraged to furnish their rooms with their personal belongings thereby retaining their links with their previous lives. The majority of the rooms had en suite facilities. The occupants of these rooms valued these facilities as they afforded them considerable privacy and protected their dignity. The bedrooms varied in size from one that was described by the occupant as ‘cosy’ to another that was more like a bed-sitting room. One of the smaller bedrooms obtained natural light through a skylight and through the door. The skylight had a blind that the occupant of the room was unable to operate. This was one of the bedrooms that had been identified by the registered provider as needing to be replaced. It was apparent that the residents had considerable pride in their accommodation by the way that they insisted on showing it to the inspector. All of the rooms had an emergency call-point. A call-point was tested in one bedroom and a member of staff promptly responded. The registered providers were aware of the shortcomings of the premises such as the lack of a passenger lift and the lack of storage space. They are intending to address these shortfalls by undertaking a major development and refurbishment programme and at the same time increasing the capacity of the home by nine beds. The lack of a passenger lift meant that only ambulant residents could be accommodated on the upper floor except in the old part of the property where a stair lift had been installed. On occasions when the health/mobility of a resident had deteriorated they had been moved to the ground floor. Adequate numbers of baths and showers were available for the current number of residents being accommodated (8:1 ratio). The number of baths would be increased with the proposed re-development of the premises. The baths had hoists available to assist those residents with mobility problems. A manual hoist was also available. The records confirmed that this equipment had been regularly serviced. The hot water outlets accessible to the residents had been fitted with thermostatic valves to ensure that the hot water temperature remained within safe limits to prevent scalding. The temperature of the hot water had been regularly checked and recorded. The home had adequate laundry facilities but on the day of the inspection visit one of the commercial standard driers had become unserviceable. This had been temporarily replaced by a domestic drier but due to the lack of available space it had been located in the main corridor which possibly gave a poor Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 18 impression for visitors to the home. The residents said that they were very satisfied with the standard of the laundry service and that their soiled laundry was laundered daily. It was also confirmed that the residents’ towels and flannels were changed twice a day on grounds of hygiene. On the day of the inspection visit all of the residents were dressed in clean and appropriate clothing. The home had a secluded rear garden that had suitable seating for the residents. It was apparent that the garden area was well used particularly during the summer months. Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 29 and 30 The service users were supported by a well trained staff team. People who use the service experience adequate quality outcomes in this area. EVIDENCE: In the pre-inspection questionnaire provided for the Commission for Social Care Inspection (CSCI) by the registered provider, the total number of care staff hours appeared considerably less than that recommended by the Residential Staffing Forum. However, the registered provider stated that the care hours in the questionnaire did not include the hours of the three assistant managers who also undertook a care role and that, at no time during the waking day, were fewer than three care staff deployed. On the day of the inspection visit there were three care staff on duty plus two assistant managers and a number of ancillary staff. Nevertheless, the outcome for people who use the service was questioned in some of the staff surveys provided for the CSCI which included comments such as, ‘Not enough one-to-one and not ample activities’ and ‘I feel that there is not enough time spent with residents’. There was also a suggestion that a few Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 20 residents were got up early (from 6 a.m.) to alleviate the pressure on the day staff. The staff on duty at the time of the inspection visit did not agree that staffing levels led to a shortage of activities or individual attention. Over 50 of the care staff had achieved a National Vocational Qualification at level 2 or above. From discussions with the staff and an examination of the records it was evident that the staff had undertaken a range of training courses covering statutory and professional subjects. The staff training programme was supported by the services of an external training organisation. The registered provider said that the training records were left in a state if disarray by the former registered manager and were having to be redeveloped. The home’s Administration Support Officer had taken on this task. The staff had been provided with a copy of Code of Conduct issued by the General Social Care Council. The home had an appropriate staff recruitment and selection procedure that involved prospective staff submitting a formal application, undergoing an interview and being appropriately vetted. It was, however, noted from the information provided by the registered provider that a considerable number of staff had, over the last few years, commenced employment in the home before the results of a Criminal Record Bureau (CRB) check had been received. According to the registered provider these staff had undergone a Protection of Vulnerable Adults (PoVAFirst) check before starting their employment and had been appropriately supervised until the outcome of the CRB check was known. A specialist company provided support and advice on staff employment issues. Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32,33, 35 and 38 The home is going through a period of transition during which the registered provider is working to re-establish the home’s management systems with priority given to the safety and welfare of the service users. People who use the service experience adequate quality outcomes in this area. EVIDENCE: Since the previous inspection visit the registered manager had resigned. Following his resignation the registered providers had identified a considerable Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 22 number of shortfalls particularly relating to staff management and record keeping. At the time of the inspection visit the registered provider and the staff were in the process of addressing these shortfalls. Following the departure of the registered manager the registered provider had taken over the role of manager, a post she originally held. She was in the process of training two care managers with the view of applying to have them jointly registered, along with a business manager, with the Commission for Social Care Inspection. At present neither of the trainee managers had achieved the required qualification. They had commenced their Registered Manager’s Award but the company providing the support and assessment had apparently gone into administration. The provider had developed a quality assurance process that included obtaining the views of the service provided from the residents and visitors to the home. Evidence was available to confirm that the registered providers had audited the quality of the service and the actions identified by the audit incorporated into the annual business plan. Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 23 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 4 3 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 24 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 OP3 Regulation 4(1)(d) Requirement Confirmation must be provided in writing for all prospective residents and/or their representative confirming that having regard for the preadmission assessment the care home is suitable and is able to meet all of the resident’s assessed needs. The CSCI is to be informed when all of the revised care plans are complete and up to date. They must clearly identify all of the primary needs of the residents along with the actions required by the staff in order to meet those needs. The care plans should be cross-referenced with other records so that it can be confirmed that the staff actions have been carried out. Timescale for action 01/08/07 2 OP7 15 01/09/07 Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 25 3 OP29 19 No prospective staff must be employed in the home without completing a full vetting procedure including a CRB and a POVA check. In order to protect the residents a POVA First check must only be undertaken in exceptional and justifiable circumstances. 01/08/07 4 OP31 9 Before applying for registration confirmation must be provided for the CSCI that the applicants for registration have obtained, or 01/09/07 have commenced, the Registered Manager’s Award/NVQ level 4. 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 OP2 Good Practice Recommendations Whilst the rationale is accepted for issuing a resident with a permanent contract at the end of a trial period, it is recommended that an interim contract along with the terms and conditions of residence are provided for prospective residents before they are admitted into the home. This minimise any possibility of misunderstanding between the home and the resident. In order to ensure that a prospective resident’s needs can DS0000019701.V339712.R02.S.doc Version 5.2 Page 26 2 OP3 Northgate House 3 OP10 4 OP15 5 OP19 be met by the staff of Northgate House and that those needs fall within the remit of the home, it is recommended that all prospective residents are provided with a preadmission assessment regardless as to whether a placing authority has undertaken an assessment. Staff should be made aware of the need for respecting the residents’ dignity by allowing them to choose a biscuit to have with a cup of tea. It is also recommended that they are reminded of the basic hygiene rules of not handling food if at all possible and are reminded of the correct way to handle cups and drinking implements used by the residents. The menus should be reviewed to ensure that there is a genuine choice of lunch for the residents and that the food is suitable for all of the residents even those who have difficulty in chewing and swallowing. Action should be taken to ensure that the sunblind for the skylight in room 12 can be operated by the occupant of the room so that they can control the amount of sunlight coming into the room. Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Northgate House DS0000019701.V339712.R02.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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