Inspection on 11/02/09 for Northleigh

This inspection was carried out on 11th February 2009.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Northleigh 12/12/06

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Northleigh 187 Rockingham Road Kettering Northants NN16 9JA     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Ann Wiseman     Date: 1 8 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 34 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 34 Information about the care home Name of care home: Address: Northleigh 187 Rockingham Road Kettering Northants NN16 9JA 01536312138 01536513277 robbierroyden@yahoo.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Minster Pathways Limited Name of registered manager (if applicable) Mr Martin Hirst Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: No person below the age of 35 years who falls within the category of Learning Disability (LD) may be admitted to Northleigh No persons to be admitted into Northleigh under categories LD/LD(E) where there are 12 persons in total of those categories/combined categories already accommodated within the home The maximum number of persons accommodated within Northleigh is 12 Date of last inspection Brief description of the care home Northleigh is situated approximately half a mile from Kettering town centre and provides personal care for up to twelve adults with learning disabilities. The house is set off a main residential road leading into the town centre. The location of Northleigh allows people good access to the resources of the local community. Internally the home is decorated in a homely way is furnished comfortably. There are ten single rooms and one double room. To the rear of the property there is a small area of garden and a patio area. The home provides long-term placements; some people have Care Homes for Adults (18-65 years) Page 4 of 34 care home 12 Over 65 12 12 Brief description of the care home lived at the home since it opened approximately twenty years ago. The fees per week vary between £500 to £950. Care Homes for Adults (18-65 years) Page 5 of 34 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced inspection, which was carried out over two days. On the first day we arrived at 1.30pm and left soon after 5pm, we returned on a later date for a few hours to finish the inspection as we were unable to inspect staff files because a heavy snowfall meant the acting manager couldnt use her car and she left the keys to the filing cabinet at home attached to her car keys. The home hasnt had a registered manager since the previous one left two years ago, the person in charge is acting up to the managers post and has not followed the appropriate procedure to test that she is a fit person to run the service. However she was on duty when we arrived and facilitated the inspection in an open Care Homes for Adults (18-65 years) Page 6 of 34 and helpful manner. Whatever files and documents we asked to see were quickly produced and were well ordered. During the day we had a look around the home and talked to the staff on duty and some of the people who live there. We looked at information belonging to three people and the personnel files of three of the staff. We also assessed some of the homes policies and procedures and sampled a random selection of the health and safety files and records. Before the inspection the acting manager has sent us the Annual Quality Assurance Assessment (AQAA) she had completed. The AQAA is a self-assessment that focuses on how well outcomes are being met for people living in the home. It also gave us some numerical information about the service. The AQAA was sent to us within our set timescales, it was hand written and the information given was brief and didnt always give examples to illustrated the statements it made. It would be beneficial if the AQAA is completed electronically as it is required to be produced annually and if it had been done on the computer, it would only need to be updated and sent to us without having to be completely rewritten. Prior to the inspection we sent surveys to the home for distribution amongst the people there, their relatives and the staff. Most of the people living in this home have communication difficulties so staff supported them to fill their surveys in, one relative responded to theirs and five surveys were returned by staff members. The majority of them said good things about the home. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 Care Homes for Adults (18-65 years) Page 8 of 34 7535. Care Homes for Adults (18-65 years) Page 9 of 34 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 34 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People thinking of moving into this home are offered enough information to enable them to make an informed choice about staying there and everyones needs are assessed before they move in and they are given an opportunity to visit the home first. Evidence: The homes statement of purpose and user guide are both available and are clear and comprehensive, the format is generic to Minster Pathways Limited and uses pictures to illustrate it. The service manager told us that they are in the process of being updated and we discussed how the document could be made more personal to this home by including photographs of the house, the inside of the home and the surrounding area. The statement must be amended to give people more individual information about Northleigh, what services it offers and what facilities are available in the local community. We examined three peoples files during this inspection and they contained Care Homes for Adults (18-65 years) Page 11 of 34 Evidence: comprehensive assessments carried out by the service prior to them moving in to ensure that the home can meet their needs and that care offered is fully appropriate. The manager told us that people thinking of moving in are given the opportunity to visit the home before they make a decision and there will be a review before the placement is made permanent. There is a Company policy and procedure regarding how to properly admit people into the home. Care Homes for Adults (18-65 years) Page 12 of 34 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this home have care plans and are assisted to make decisions about their life and are consulted about the way they want to live. People are enabled, through risk assessments, to take some risks as part of an independent lifestyle. Staff are trained to respect personal information in a way that will maintain confidentiality. Evidence: The files and care plans of three people were examined, they were very detailed and reflected the needs and aspirations of the person involved. They have been updated since the last Inspection and have been reviewed at regular intervals. One persons health has deteriorated recently and on the day of the inspection they were very poorly, it meant that staff were busy, but they managed well and made sure that the person was cared for and were still able to support everyone else and put up with the inconvenience of having an inspector in the house. While checking the care plans we looked at this persons file and found that it had been updated to incorporate Care Homes for Adults (18-65 years) Page 13 of 34 Evidence: the changes to their health and contained guidelines on how to manage their care. House meetings are held where everyone gets a chance to voice their feelings and make requests. People are asked their views on important issues in the meetings and these are recorded, the topics involved food, holidays and outings. The files contained a range of risk assessments, which addressed activities chosen by people that may present risks to their safety, these included safety in the community. The home does not have its own transport and staff use their own cars to take people out and about to appointments etc, but there are no risk assessments to cover this and no safeguards have been put in place to make sure that the cars used are safe and legal to use. Risk assessments must be carried out that cover the risk of staff travelling with people in a car without an escort, what will happen in the event of an accident or breakdown and who is responsible for checking insurance and licences. Induction training includes the importance of keeping confidences. When not in use private information is stored in a locked cupboard in the office and is not left lying around in communal areas. Care Homes for Adults (18-65 years) Page 14 of 34 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People at Northleigh are able to advance personal development by attending adult education classes. A full range of activities is offered in and out of the house that makes people a part of the local community. Friends and family are welcomed in the home and peoples rights and responsibilities are recognised and upheld. Food offered is varied and served in pleasant surroundings. Evidence: We spoke with two people who said they were happy living in the home and with what they do with their leisure time and said they were able to get out and about. We were told that people attend colleges to further their personal development and take part in leisure activities such as bingo, karaoke, the Kaleidoscope club, going to pub, the cinema, bowling, listening to music and eating out. Entertainers visit the house from time to time and we were told that these are very popular. Care Homes for Adults (18-65 years) Page 15 of 34 Evidence: Sometimes House meeting notes showed that people are consulted on holidays and activities and that trips are planned for the future. Staff said that residents use a range of community facilities including local shops, pubs and the park as well as attending specific support groups. However the acting manager told us that there is no activity plan and that there was no log of what activities take place and who attended them. It is important that a central record is kept of planed activities and if they went ahead so that the manager can monitor which activities are popular. It will be a useful tool to evidence that the home is proactive in providing activities that are tailored to meet peoples individual needs and aspirations. People said they could invite visitors to the home and that there were no restrictions on visiting times. The service has a policy on intimate relationships, which respects the ability of people to have consensual relationships. People are helped to keep their rooms clean and tidy by the staff. They are also asked to make suggestions for the menu, which is varied and offers a balanced diet. The food cupboards, freezers and fridge were well stocked with fresh, tinned and frozen food as well as snacks and treats, there was ample fresh fruit on the dinning table that people are free to help themselves to. The dinning room is a large attractive room and is a pleasant area to enjoy a meal. Care Homes for Adults (18-65 years) Page 16 of 34 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This home records peoples personal care needs in a way that enables them to be supported how they want to be. People have access to doctors and specialist care and medication is managed properly. Evidence: We looked at three care plans and found that, peoples support needs were recorded and they were written in a way that reflected their personal preferences. The care plans were reviewed regularly and when care needs change. We found evidence, in the files we examined, that people have access to medical practitioners as and when they need to, they also get support from specialists such as speech and language therapy, psychology, psychiatric support, dentists and opticians. We examined the medication and its records and found that they were as required. We were told that all staff are trained before they can deal with it, and the manager said that she assesses staff competence before allowing them to dispense medication. The home has a policy and procedure for the safe administration of medications, which Care Homes for Adults (18-65 years) Page 17 of 34 Evidence: staff can refer to. We examined how the controlled drugs (CD) are managed and found that the number of tablets corresponded to those recorded and that it is dispensed by two people who both signed for the medication. A record of this was being kept on the MAR sheet. Under best practice guidelines it is required that CDs are recorded in a separate book. In 2007 the law changed regarding storing controlled drugs and the following is our guidance. All care homes, whether providing nursing or personal care, must now keep controlled drugs (CD) in a controlled drugs cupboard. In brief, the requirements for CD storage are: They must be stored in a metal cupboard of a specified gauge, with a specified double locking mechanism and it should be fixed to a solid wall or a wall that has a steel plate mounted behind it and should be fixed to the wall with either Rawl or Rag bolts. It is sometimes believed that controlled drugs should be stored in a cupboard within a cupboard. This is not the case. Records of the use of controlled drugs in a CD register are expected as good practice but this is not a legal requirement. When controlled drugs are received and administered a record must be made on the MAR chart and in the CD register. When controlled drugs are returned to a person leaving the home or sent to a pharmacy for disposal a record must be made in the CD register and in the returns book. People can keep and take their controlled drugs themselves, following a robust risk assessment. If a person has been assessed as able to manage their controlled drugs independently then no record in the register is required of each individual dose taken. If the home receives or returns their controlled drugs then a record of this must be made. Care Homes for Adults (18-65 years) Page 18 of 34 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaint policies and procedures are in place and people are protected from abuse by staff being properly trained in safeguarding and managing challenging behaviour. How peoples money is managed in the home should be tightened up. Evidence: The home has complaint and safeguarding policies and the complaints procedure is displayed throughout the home. The acting manager told us that they havent received any complaints since the last inspection and we havent received any regarding the service either and when we examined the complaints procedure we found it reflected the national minimum standard. There are residents meetings held when all residents are invited to attend and share their views about the home. A record of these meetings is kept for reference. People have bank accounts in their own names and, usually, only small amounts of money are kept in individual tins in the home for everyday expenses. We examined the money and records belongings three people and found that the money in the tin corresponded with the amount recorded. The money is locked in a cabinet in the office, which is normally locked when not in use, but all care staff have access to the money and the acting manager told us that it Care Homes for Adults (18-65 years) Page 19 of 34 Evidence: is not usual practice for it to be checked and handed over at shift changes. One tin contained a large amount of money and it would be difficult to trace back when it went missing or who had responsibility for it if it were lost. We require that three steps are taken to keep peoples money safe; It is not advisable for the home to hold large amounts of peoples money in cash, if it cant be avoided the bulk of the money should be stored separately and only accessed by the manager. Only small amounts should be left in the tin that is accessible to the rest of the staff. The responsibility for the money must be handed over to the next shift leader at the end of each shift, when it will be counted and signed for. The policies and procedures must be reviewed so they reflect this practice. We saw evidence that staff undertake training in safeguarding and managing challenging behaviour, so they will be able to defuse and manage challenging situations. Care Homes for Adults (18-65 years) Page 20 of 34 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This home is safe, comfortable, clean and hygienic. Bedrooms suit peoples needs and lifestyle, but locks need to be fitted to some of the rooms to protect peoples privacy. There are sufficient bathrooms and toilets. Evidence: Northleigh is homely, well decorated and mainly safe. The home has a maintenance person who manages simple repairs and keeps the home maintained. There is a garden that is easily accessed, it was covered in snow while we were there so we are unable to comment on its appearance on this occasion. There is a cleaner who works 20 hours a week to help people keep the home and their rooms clean and tidy. We looked at several bedrooms, they were individual to each person and were clean and tidy. Not all of the rooms had the required minimal furniture and equipment, the acting manager told us that this was how people wanted their rooms but this was not reflected in peoples files. It is completely up to the people living in the home to decide what they have in their room but these wishes must be recorded in their care plans. If furniture has been removed for other reasons this must also be noted. The communal Care Homes for Adults (18-65 years) Page 21 of 34 Evidence: rooms are spacious and furnished in a contemporary manner. Not all of the rooms had locks to enable people to lock their rooms to protect their possessions when they are out or if they want to ensure privacy. All bedrooms must be fitted with locks that can be easily opened from the outside in the event of an emergency, care must be taken that Yale type locks are not fitted which have a snib lock that, if used, prevents access from the outside with a key. The cellar is accessed via steep concrete steps, which are difficult to use and could be a hazard to people who have mobility problems. The cellar was not locked on the day of the inspection, it must be kept locked at all times to avoid accidents. There are sufficient bathrooms and toilets to meet peoples needs and some have been fitted with equipment and aids to maximise independence. Care Homes for Adults (18-65 years) Page 22 of 34 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are aware of their roles and responsibilities. The home has recruitment policies and procedures in place that are being followed. Staff are qualified, training is in place and staff are receiving supervision. Evidence: Staff personnel files are kept in the home and we examined three of them, which we found to contain all the required information. This shows that safeguarding procedures are carried out prior to people being employed at the home. The files also contained job descriptions, evidence of staff training and of their qualifications. We are told in the AQAA that the home has a training plan, which is revised every year to meet the assessed training needs of the staff and we were shown the training matrix. We spoke to two staff members on this occasion. They confirmed that they undertook CRB checks and had two references taken before they started work. They also told us that they had an induction and received the mandatory training as well as some that are more relevant to the client group, such as mental capacity act training, mental health care and care planning. While talking to us they displayed a good knowledge of the people in the home and Care Homes for Adults (18-65 years) Page 23 of 34 Evidence: understood their needs. Information given to us in the AQAA indicates that the home has met the minimum requirement of 50 of its staff having attained an NVQ 2 in care or it’s equivalent. It tells us that there are twelve staff working at this home and nine of them have the qualification. The rota showed that the staffing level was adequate to offer the people individual support, continuity of care and to be able to manage emergency situations. But one persons relative feels that people would benefit if there were more staff on duty, they said in the survey they returned to us, More staff on duty would allow my relative to go out more often. We recommended that the acting manager should reassess peoples needs to make sure that there are enough staff on duty at busy times to allow people to get out and to take part in social activities. Staff reported that they receive one-to-one supervision, and we saw the supervision notes in the personnel files that confirmed this, however they also showed that supervision is not taking place as often as it should be, which is at least six supervision sessions a year and an appraisal once a year. The acting manager has assured us that she plans to schedule supervisions so that she can attain this number. Care Homes for Adults (18-65 years) Page 24 of 34 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This home is being well run by an acting manager and the ethos of its management is empowering to the people living there and their views underpin its running, But a manager must be appointed. The policies and procedures and the record keeping protect people’s rights and best interests and Health and safety is promoted and necessary checks are made and records kept. Evidence: The previous manager left soon after the last inspection and the person running the home at the moment is acting up. She has not been appointed as the manager by the company nor has she been put forward for registration by us. This means that the home has not had a manager for the past two years. This is not acceptable and steps must be taken to formally appoint a permanent manager and to apply for their registration with us so that they can undertake the fit person interview, so that their abilities and integrity can be tested to see if they are a fit person to run a home for vulnerable people. Care Homes for Adults (18-65 years) Page 25 of 34 Evidence: The acting manager was at the home when we arrived and she facilitated the inspection, which she did in an open and helpful way and was able to produce everything we asked for. She proved knowledgeable about the running of the home and the people living in it, she was organised and comments we received indicated that she is well liked by the people living in the home and the staff working with her. The home sends annual surveys to staff, people in the home and their relatives. Once they are returned the information is collated and action is taken when shortcomings are highlighted. We had a discussion with the acting manager and the service manager about the benefits of producing a short report about the survey and its outcome that could be given to interested parties, including people living in the home and their families. The acting manager undertook to carry this out when the latest survey is complete. House meeting are held where people are encouraged to speak their mind about how the home is run and how it can be improved. Records are kept of these meetings and we were able to see them. The organisation’s polices and procedures are comprehensive and are reviewed and updated as legislation dictates. Records are kept up to date and are stored appropriately. Personal details are stored in a cupboard and are not left unattended, staff are asked to read and sign the organisations policy on confidentiality when taking up their post. A sample of health and safety records was inspected and was found to be in order. Fridge and freezer temperatures are taken and recorded daily and we saw that portable appliances tests (PAT) are done annually. We noticed that the fire extinguishers had not been serviced this year and the acting manager undertook to arrange for it to be done immediately. When we returned for our second visit the safety checks had been done and we were told that when the service company carried out its checks on the fire safety equipment they overlooked the extinguishers. Care Homes for Adults (18-65 years) Page 26 of 34 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 27 of 34 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 Risk assessments must be carried out that cover the risk of staff travelling with people in their own car without an escort, what will happen in the event of an accident or breakdown and who is responsible for checking insurance and licences. Whenever staff drive with people from the home in a car, care must be taken that they have considered all possible outcomes. Something as simple as a flat tyre can become a difficult situation if people become stressed or worried. When using staffs own cars, someone needs to take responsibility that the vehicle is safe and legal to use. 22/06/2009 Care Homes for Adults (18-65 years) Page 28 of 34 2 14 16 A programme of activities must be developed that meets each individuals assessed needs and preferences. Records will be kept of which of the activities take place, who takes part and how popular they were. This will enable the acting manager to monitor activities and will help her plan future events. Keeping records of the activities centrally will provide evidence to regulatory bodies that this requirement is being met. 22/07/2009 3 20 13 A controlled drug register must be obtained and used to record its use and delivery. Using the mar sheet to track the use and quantities of controlled drugs in the home makes it difficult to audit their use and administration because the mar sheet is removed for the medication book monthly and single sheets can get lost or go missing so the audit trail will be broken. Use of a CD register is more practical and keeps the records in one place. 03/07/2009 4 23 16 The homes policies and procedures on managing peoples monies must be reviewed to reflect their policy of keeping peoples 22/06/2009 Care Homes for Adults (18-65 years) Page 29 of 34 cash in the home and what safeguards should be in place. Guidelines must be developed on how much cash should be kept at the home at any one time and how it should be managed when keeping large amounts in the home is unavoidable. Also staff must be made aware of the importance of handing it over and checking it regularly so that any irregularities can be quickly identified and dealt with. 5 23 16 The responsibility for the 03/06/2009 money must be handed over to the next shift leader at the end of each shift, when it will be counted and signed for. This way it is clear what money is in the home at all times and if it goes missing the responsible person can be identified and called to account. Also it will be noticed immediately that money has gone missing and there will be a better chance of recovering it. 6 23 16 It is not advisable for the 22/06/2009 home to hold large amounts of peoples money in cash, if it cant be avoided the bulk of the money must be stored separately and only accessed by the manager. It is better to take steps to Care Homes for Adults (18-65 years) Page 30 of 34 protect peoples money and remove temptation than to find that when monies are lost or stolen it cant be determined when the money went missing or who was responsible for it at the time. 7 24 12 The door to the cellar must be kept locked at all times. The access to this room is via steep concrete steps, which are difficult to use and could be a hazard to people who have mobility problems. 8 26 12 Peoples bedrooms must be 03/07/2009 fitted with a lock that can be overridden to enable staff to gain access in the event of an emergency. People are entitled to privacy and to be able to protect their belongings by locking their bedroom doors. It is not acceptable for a home to say this person doesnt want to lock their door as an excuse not to provide them. It is not relevant whether a person has the capacity to use the lock, bedrooms should be locked whenever people are out during the day and especially when they are absent for any length of time, while they are on holiday for example. 9 37 8 Minster Pathways must appoint a manger to this home. 03/07/2009 03/06/2009 Care Homes for Adults (18-65 years) Page 31 of 34 The person who has been in charge of the day to day running of this home has not been appointed as the manager but has been acting up for the last two years. This is not an acceptable practice as it fails to show the acting manger that the company has confidence in her skills and could lead to her feeling unappreciated and disempowered, which could undermine her confidence and authority. 10 37 9 The person in charge of the day-to-day running the home must be judged a fit person to manage a care home by taking part in our registration process, therefore once a manager has been appointed they must immediately apply for registration with us. The home needs someone to manage it that has a good understanding of the national minimum standards and has shown a willingness to comply with them so that people can be confident that they will be properly cared for in a safe environment. 03/07/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. Care Homes for Adults (18-65 years) Page 32 of 34 No. Refer to Standard Good Practice Recommendations 1 1 The statement of purpose and user guide should be amended to give people more individual information about Northleigh, what services it offers and what facilities are available in the local community and they should include photographs that are more specific to the home. A relative feels that people should be able to get out more, so it is recommended that the acting manager should reassess peoples needs to make sure that there are enough staff on duty to allow people to get out and to take part in social activities. 2 33 Care Homes for Adults (18-65 years) Page 33 of 34 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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