Inspection on 10/08/05 for Northlea Court

This inspection was carried out on 10th August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Northlea Court 10/02/09

Northlea Court 04/04/07

Northlea Court 07/12/05

Northlea Court 09/03/05

Northlea Court 23/06/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Northlea Court Northumbrian Road Cramlington Northumberland NE23 1XX Lead Inspector Suzanne McKean Unannounced 10 August 2005 09:30 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. Northlea Court B53-B03 S551 Northlea Court V227178 100805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Northlea Court Address Northumbrian Road Cramlington Northumberland NE23 1XX 01670 737735 N/A northlea.court@fshc.co.uk Tamaris Healthcare (England) Ltd 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) Pamela Ann Scoble CRH 50 Category(ies) of OP Old age (50) registration, with number of places Northlea Court B53-B03 S551 Northlea Court V227178 100805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home can accommodate one service user under the age of 65 requiring nursing care. At the time that this named service user no longer requires the placement this condition is to be removed. CSCI must be informed at this time. Date of last inspection 9th March 2005 Brief Description of the Service: Northlea Court is situated to the west of Cramlington and is a purpose built two-storey building set in its own grounds. It is of traditional brick built design with an apex-tiled roof and is shaped around the car park area, which is at the front of the building. The home is on a bus route and has a small shopping centre with a pharmacy and a health centre close by as well a public house. The home is in close proximity to a local school giving the opportunity for a close relationship to have been developed. Northlea Court B53-B03 S551 Northlea Court V227178 100805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over a period of 5 hours on one day by the inspector, who has visited the home on a number of previous occasions. The manager was on duty during the visit and accompanied the inspector a tour of the premises Eleven residents were spoken to during the visit and six relatives and the inspector also spoke to three of the staff the in process of the inspection visits. During the inspection the records examined included, four care plans and medication records, some training records and the records for complaints as well as the accident records. There was one requirements and two recommendations identified during this inspection, the recommendation is a long standing one and has been the subject of separate discussion with the company. What the service does well: What has improved since the last inspection? At the last inspection there was only two requirements made only one of which remains unmet, this is to reissue the amended contract and is a company issue, there is an expectation that this will be met by the identified time. Northlea Court B53-B03 S551 Northlea Court V227178 100805 Stage 4.doc Version 1.30 Page 6 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. Northlea Court B53-B03 S551 Northlea Court V227178 100805 Stage 4.doc Version 1.30 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 Northlea Court B53-B03 S551 Northlea Court V227178 100805 Stage 4.doc Version 1.30 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) 3, 6 There is a comprehensive assessment undertaken by the staff prior to admission, which forms the basis for the development of the care plan. The home does not offer intermediate care. EVIDENCE: Four care plans were examined and each has comprehensive pre-admission assessments, which were undertaken by the Manager or the senior staff in the home. The pre-admission assessment is kept in a separate file once the information has been used to create the care plan. The residents also have a care management assessment, which is provided, to the home on admission and from these documents an individual care plan is produced. The home is not registered for, and therefore does not provide, intermediate care. Northlea Court B53-B03 S551 Northlea Court V227178 100805 Stage 4.doc Version 1.30 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, 8, 10 Individual care planning is undertaken and the care is being delivered in line with these plans. The residents are having their needs met. Residents are confident that the staff treat them with respect and maintain their privacy so far as possible when delivering care and throughout their daily life. EVIDENCE: Each resident has an individual plan of care, which is based on the admission assessment and is then added to during the placement. Four care plans were examined and they were completed to a good standard. There was evidence that relevant assessments are available for the nutrition, wound care, moving and assisting, and continence promotion as well as a dependency score. There were risk assessments in place for specific interventions for example use of bed rails. The plans showed that they are regularly reviewed and updated and that reviews are regularly held with residents and their representatives. The care plans showed that the residents have access to all NHS services and facilities. There was a good range of pressure relieving mattresses in use for the prevention of pressure sores. The recording of the nursing action taken for wound care was satisfactory with evaluations being dated and signed. There Northlea Court B53-B03 S551 Northlea Court V227178 100805 Stage 4.doc Version 1.30 Page 10 was evidence that the home seek expert advice from external professionals and during the visit there was a visit from the McMillan Nurse and a General Practitioner who undertakes a weekly visit to the home. This suggests their willingness to ensure that they are using best practice in their care. The staff spoken to are aware of the need to maintain residents privacy are doing so as part of their delivery of care. The residents interviewed were complementary about the care they received and said that the staff treat them in a kind and caring way. An example of the comments made were that the staff were “lovely” and “we couldn’t ask for better staff”. Two specifically said staff would knock on their door before entering their room. The staff were observed throughout the day to address the residents by their preferred name and there was a good relationship noted between the residents and the staff. Some of the relatives and residents singled out specific staff for praise however these were generally different for each and suggested that the majority of the staff were favoured by different families. Northlea Court B53-B03 S551 Northlea Court V227178 100805 Stage 4.doc Version 1.30 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) 15 The food being served is being prepared safely by knowledgeable staff and offers choice to the residents. The home offers the resident a balanced diet and there is sufficient quantity of both food and fluids to meet their needs. Staff are aware of the importance of a balanced diet and the way it is served. EVIDENCE: The residents are offered three meals a day with choices for the main meals and residents on the day were seen eating heartily one asked said that the “food is really nice”. The meal being served was ample portion size, hot and well presented on the day it was Ham, with roast parsnips, mashed potatoes and broccoli, the desert was jam and coconut sponge and custard. Residents were offered assistance in a discreet manner. Second helpings and alternatives to the main and dessert course were available. A variety of cold drinks were available throughout the meal and hot, cold drinks, biscuits were offered at intervals in the day when drinks trolleys were circulated. There was an ample supply of frozen, tinned, dried and fresh food available all of which was appropriately stored. The kitchen staff were aware of residents specialist needs including how to fortify foods for those who have poor appetites or those who have lost weight although they rely on care staff to request for specific residents. Northlea Court B53-B03 S551 Northlea Court V227178 100805 Stage 4.doc Version 1.30 Page 12 The kitchen was clean and well organised. The kitchen records are being kept appropriately and were examined these include recording the temperature of the food being served, the fridge and freezer temperatures and the cleaning schedule. Northlea Court B53-B03 S551 Northlea Court V227178 100805 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 The home ensures that the residents and relatives are made aware of the complaints policy and that it is available in a variety of places. There is a system for managing and dealing with complaints, which makes it possible for them to be investigated and action taken to address any issues identified. The residents are protected by ensuring that the staff are given information regarding Protection of Vulnerable Adults and whistle-blowing as well as reporting concerns to the Manager. It is recommended that this also be delivered through formal training programmes as planned. EVIDENCE: The complaints procedure is available in the service users guide and a copy is available at the front entrance as well as being displayed in the home. The records of the complaints made to the home were examined, there has been no new complaints recorded since the last inspection Two of the residents who were interviewed during the visit understood how to make a complaint, and could identify the way this would be dealt with. Three relatives who was visiting the home was aware of the complaints procedure but felt that there concerns were being dealt with before the need for formal complaint. Written guidance is included in the company policies and procedures regarding the protection of vulnerable adults. Staff confirmed that they knew about the guidance and could identify the action they would take if they were made aware of or had any concerns regarding this issue. Staff are being given this Northlea Court B53-B03 S551 Northlea Court V227178 100805 Stage 4.doc Version 1.30 Page 14 information during induction and via supervision however training on protection of vulnerable adults has been developed and it is recommended that this be implemented as planned. Northlea Court B53-B03 S551 Northlea Court V227178 100805 Stage 4.doc Version 1.30 Page 15 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) 26 The home is clean, tidy and there was no unpleasant odour during the visit. There are suitable toilets and bathrooms, which are well equipped and nicely decorated. The necessary specialist equipment for the control of infection is provided in the home and the staff were aware of their responsibilities in this respect. EVIDENCE: The home is clean and was odour free. The residents’ bedrooms were personalised reflecting individual choices and preferences and three residents asked about their bedrooms said they were happy with the decoration and that they were kept clean by the staff. The on suites are equipped with disposable paper towels and waste bins but do not have liquid soap available, this would assist in control of infection. The laundry was clean, organised and well equipped. The sluices were tidy, clean and odour free and the disinfectors operational. Staff followed infection control policies throughout the day. The light and emergency call cords were all clean and all emergency cords reached skirting level. Northlea Court B53-B03 S551 Northlea Court V227178 100805 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The home is staffed with appropriate numbers of staff and there are qualified nurses on duty in sufficient numbers to meet the needs of the residents. There has recently been a change in the shift pattern and the staffing levels, this will be monitored to judge the appropriateness of the change. EVIDENCE: On the day of the visit there was one qualified nurse on each floor, one of which was the Deputy Manager, and six carers to cover both floors. There was also one domestic, two kitchen staff, one of which was the acting cook and one laundry assistant on the day of the visit. The Manager was supernumery to the staffing levels. The staffing levels have been reduced recently to have one less carer in the afternoon and evening, this was carried out with shift pattern changes. There has also been a drop in the occupancy from 50 to 43, due to general market factors, and the effect of all of these changes are currently being assessed. It is expected that this will be reviewed as the numbers of residents and the dependency levels change to ensure staffing levels remain appropriate. Staffing rotas showed that the Manager is ensuring that enough staff are on duty to meet the staffing levels agreed recently with the CSCI. It was noted that when sickness and staff holidays occur these occasions are being covered by the home staff. However, when this is not possible, late reporting does occasionally result in fewer staff being on duty for short periods. Northlea Court B53-B03 S551 Northlea Court V227178 100805 Stage 4.doc Version 1.30 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 38 The Registered Manager, Mrs Scoble, ensures that she has systems in place to make sure that the home is managed effectively taking into account the needs and wishes of the residents. She is continuing to ensure safe working practices in the home in line with the company policies and procedures. EVIDENCE: There are clear lines of accountability both in the home and within the company. The manager maintains her Professional Portfolio according to the NMC (UKCC) requirement for updating to maintain her nursing registration. The records to support the Managers confirmation that she ensures safe working practices in relation to moving and handling, first aid, food hygiene and infection control were in place and on examination were satisfactory. Northlea Court B53-B03 S551 Northlea Court V227178 100805 Stage 4.doc Version 1.30 Page 18 There was evidence that the home manager takes the necessary action to ensure the health and safety of the service users. This is supported by the policies and procedures examined and by discussion with the Manager. Northlea Court B53-B03 S551 Northlea Court V227178 100805 Stage 4.doc Version 1.30 Page 19 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 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x x Northlea Court B53-B03 S551 Northlea Court V227178 100805 Stage 4.doc Version 1.30 Page 20 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 2 Regulation 5. (1) (b) Requirement The updated statement of terms and conditions should be submitted to the CSCI and be provided to new service users on moving into the home. Outstanding Timescale for action 01.10.05 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. 2. Refer to Standard OP28 OP26 Good Practice Recommendations It is recommended that the Manager provide formal Protection of Vulnerable Adult Training for all staff. It is recommended that liquid soap is provided in the on suite areas of the residents bedroom. Northlea Court B53-B03 S551 Northlea Court V227178 100805 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Northumbria House Manor Walks, Cramlington Northumberland NE23 6UR 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 Northlea Court B53-B03 S551 Northlea Court V227178 100805 Stage 4.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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