Inspection on 19/11/07 for Northway House Residential Home Limited

This inspection was carried out on 19th November 2007.

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

The inspector 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

Northway House Residential Home... 16/06/09

Northway House Residential Home... 18/11/08

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Northway House Residential Home Limited 96 - 98 Kingston Road Taunton Somerset TA2 7SN Lead Inspector Sally Murphy Unannounced Inspection 19th November 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 Northway House Residential Home Limited DS0000070759.V355194.R01.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. Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Northway House Residential Home Limited Address 96 - 98 Kingston Road Taunton Somerset TA2 7SN 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) 01823 253999 01823 325255 Northway House Residential Home Ltd ****Post Vacant**** Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 29. Date of last inspection Brief Description of the Service: Northway House is a large detached Victorian house, situated close to Taunton town centre. Service user rooms are provided the ground and first floor. There two lounges, a conservatory and a large dining room. The home has a passenger lift, call system, and adapted bathrooms. There is a well-maintained garden at the rear of the home that is accessible to service users. Northway House is registered with the Commission for Social Care Inspection to provide accommodation for up to 29 people over the age of 65 years who require assistance with personal care. The home does not provide nursing care. The home also provides day care. The registered provider is Northway House Residential Home Ltd. Paulene Coles is the manager, and has applied to CSCI to become the registered manager for the home. Weekly fees range from £361 to £385 with additional charges being made for hairdressing, newspapers, personal toiletries, dry cleaning and telephone installation. Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and was completed by two inspectors over one day. A random inspection was also conducted by the Pharmacist Inspector from CSCI on 30th October 2007, and the findings from this visit have been included within this report. Since the last key inspection the registration of the home has changed from being a partnership to a limited company. Therefore the home is considered to be a new service for the purposes of this inspection, meaning that any previous requirements or recommendations have not been carried forward. All key standards have been assessed during the course of this visit. During the course of the visit we spoke with the manager, staff, service users and relatives. Records relating to service users, staff and health and safety were examined. Care practice was observed and a tour of the premises made. As the service has only recently re-registered with CSCI an Annual Quality Assurance Assessment and surveys were not issued. These will form part of the next key inspection for the home. The manager has been in post for three months and has submitted an application to CSCI to become the registered manager for the service. The manager made themselves available throughout the inspection and provided all documentation required. The Inspectors would like to thank the manager, staff and service users at the home for their assistance during the course of this visit. What the service does well: The Statement of Purpose and Service User Guide have been updated, and now contain all required information to enable service users to make an informed choice regarding admission to the home. The new system of care plans has provided staff with the appropriate information to meet service users needs. However this has not yet been completed for all service users. Care plans had been signed by the service user or their representative. This is good practice and is to be commended. It was evident that care plans had been updated as service user needs had changed. The management of medication is generally safe. Service users feel that they are treated with respect. Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 6 Service users are provided with a choice of meals. There is evidence that service user views are sought regarding the range of meals provided. New armchairs have been purchased for the lounges, and conservatory. One service user room has been re-decorated and new furniture purchased. A robust recruitment procedure has been followed. Two satisfactory references, a POVA First and enhanced CRB are obtained prior to a member of staff commencing work, to ensure that suitable people at employed at the home. Ms Coles has been in post for three months. She has many years experience of providing care to older people and has applied to become the registered manager for the home. People living at the home are encouraged to express their views. Resident meetings are held. At the recent meeting the provision of activities and meals was discussed. The home will keep money securely for those service users that wish them to. Appropriate records are maintained of all transactions involving service users’ monies. What has improved since the last inspection? What they could do better: Risk assessments have not always been updated as necessary. This is important to ensure that appropriate actions may be taken to minimise levels of risk. Where a service user may be reluctant to accept assistance or display aggressive behaviour, an appropriate plan must be developed so that staff respond in a consistent manner. Information relating to service users must be recorded in accordance with data protection legislation to ensure the privacy of service users. There are limited opportunities for service users to participate in social activities. This has resulted in some service users spending parts of the day sleeping. One service user stated that the lack of stimulation made it a ‘long day’. Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 7 The home has an adult abuse policy. The policy states that the home should investigate any concerns. This does not reflect good practice. The manager has agreed to obtain a copy of the recent safeguarding adult guidance produced by Somerset County Council. Service users may be at risk of injury from unrestricted window openings. Risk assessments must be completed in relation to these and any necessary actions taken. There was no evidence that newly appointed staff had been provided with induction training, this means that these staff members may not have been provided with the knowledge to safely undertake their role. Accidents must be recorded and notifications made to CSCI as necessary in accordance with regulation 37 of the Care Home Regulations 2001. Fire safety records must be reviewed and completed appropriately. This includes the fire safety policy and fire training records. The fire system and emergency lighting must be serviced and an appropriate record maintained. Hot water temperature outlets had only been checked in communal bathrooms and not in service user rooms. This means that service users may be at risk of scalding from hot water temperatures within their en suite bathrooms. Hot water must be regularly run from baths in service user en suite bathrooms to reduce the risk of Legionella. Foods stored in fridges and freezers must be covered and dated. 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. Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 8 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 Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 9 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): 1,2,4 & 5. (Standard 6 does not apply). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their families are provided with appropriate information to make an informed choice regarding admission to the home. Service users are provided with a written contract outlining the terms and conditions of their stay. EVIDENCE: Northway House has a Statement of Purpose and Service User Guide. These have recently been updated and were found to contain all of the information required. A copy of the contract of residence was provided. This provides information on the terms of their stay, any notice periods required and what is included within Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 10 the weekly fee. The written contract states that the first four weeks of admission shall be regarded as a trial period. It is recommended that the contract also include the number of the room to be occupied. There have been no new admissions since the last inspection therefore it was not possible to assess admission procedures. Some service users spoken with stated that they had chosen to live at the home following period of respite care, or day care. Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 11 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 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The new system of care plans has provided staff with the appropriate information to meet service users needs. However new care plans have not yet been developed for all service users at the home. Risk assessments have not always been updated as necessary. This is important to ensure that appropriate actions may be taken to minimise levels of risk. The management of medication is generally safe. Service users feel that they are treated with dignity. EVIDENCE: The manager has undertaken a review of the care planning system and devised a new format for recording care needs. The manager has sought to Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 12 involve the service users, and their representatives in the formation of the plans of care, and is in the process of completing these for all service users at the home. We examined three care plans in detail and two further care plans to review specific areas during the course of this inspection. Pre-admission information has been recorded and reviewed for all service users, and expanded to include service users needs and preferences. This information has formed the basis of the plans of care. It was evident that care plans had been updated as service user needs had changed. Care plans had been signed by the service user or their representative. This is good practice and is to be commended. Care plans included information on the care to be given, and desired outcome. There was an overview of each service users physical and mental health needs. Care plans were felt to be reflective of service users’ current needs. A moving and handling assessment had been completed for each service user. Service users had been weighed monthly. There are sit on weighing scales available. Tissue viability (waterlow) assessments had reviewed, but did not always have a date recorded. For one service user where the tissue viability assessment identified a very high level of risk there was an appropriate plan relating to their skin care. A diabetes care plan and risk assessment had been developed for one service user in conjunction with the Community Nurse. Individual risk assessments had been completed for each service user. A risk assessment had been completed in relation to the use of denture cleaning tablets for one service user. During the course of the inspection another service user was considered to be at risk, and the manager has agreed to complete a risk assessment for this service user and take any appropriate actions. The manager has developed a falls record that examines possible reasons for the falls and seeks to reduce the level of risk of further falls. This had been completed following a service user suffering one fall, but not on the other two occasions. For another service user the falls risk assessment had not been updated following them having two falls. Daily records for one service user evidenced that they had suffered a fall that required attention from a paramedic. However an accident record had not been completed, and a Regulation 37 notification had not been sent to CSCI. This matter was discussed with the manager during the inspection, who agreed to investigate why these records had not been maintained. Within the daily records for one service user it was noted that they could be reluctant to accept support in managing their personal care needs, and display aggressive behaviour towards staff members. A clear plan should be in place for staff to follow in these instances. Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 13 A re-admission / discharge form has been introduced to ensure that a thorough assessment is completed prior to a service user returning to the home. Care plans included evidence of service users receiving support to access healthcare services and referrals to specialist services as appropriate. A detailed record has been maintained of professional visits including the reason for the visit, whom attended and the outcome. Handover sheets were seen during the inspection. These contained personal information regarding a number of service users, and do not comply with Data Protection legislation. The management of medication was examined by Brian Brown, Regional Lead Pharmacist during his visit to the home on 30th October 2007. It was found that all medication had been stored securely, however one of the cupboards was not secured to the wall in accordance with the current regulations. Medication had been stored within the appropriate temperatures. Medication Administration Records (MARs) had been appropriately maintained. The home was advised that the quantity must be recorded when medication is received during the month. One person at the home regularly takes medicines out of the home. A record had been maintained of the medicine that had been taken out, but staff had not recorded the amount that was returned. It was not possible to determine whether one bottle of medicine was in use, or when it had been opened. This is important because the medicine has a reduced life set by the manufacturer after first use. A risk assessment had been completed in relation to the self-administration of medication, and had been signed by the home and the service user. The stock balance of Controlled drugs was checked and found to be in order. The home has a new homely remedy list in place that has been agreed with the prescribers of people resident in the home. Interaction between staff and service users was noted to be friendly and respectful. Those service users spoken with stated that staff were kind and treated them with dignity. Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 14 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): 11,12,13,14 & 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are limited opportunities for service users to participate in social activities. This has resulted in some service users spending parts of the day sleeping. Service users are provided with a choice of meals. There is evidence that service user views are sought regarding the range of meals provided. EVIDENCE: Care plans include information on service users social needs. The level of social activities recorded within care plans varied for each service user. These activities recorded included: flexercise, quiz, sing-along, Halloween celebrations, guy making and bingo. Some service users stated that they would like to go out. Others provided feedback that they had enjoyed visits from entertainers but felt that these had been ceased or reduced due to the Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 15 cost. Some service users stated that they felt that the lack of social activities was due to low staffing levels. There are two Activities Coordinators at the home, however they are not supernumerary to the staff team and therefore do not have the opportunity to focus solely on meeting service users social needs. It was noted that there was no music, radio or TV on in communal lounges, or interaction from staff members, and as a result the majority of service users were sleeping in the chairs. One service user who receives day care was sat at a dining table with their arms folded for most of the morning. No interaction was observed between staff members and the service user. This was discussed with the Manager. Service users are encouraged to maintain independence. One service user continues to clean their room. They also maintain the garden to a very high standard. A Communion service takes place in the home each month. A nun also visits the home each week to visit some service users. One relative was spoken with during the inspection. They advised that they are always kept up to date and were pleased with the care provided. Information regarding the Age Concern advocacy service is displayed. Residents meetings are held regularly, and minutes taken. A meeting was held on 20/9/07 when service users were consulted regarding activities and meal times. Service users made suggestions regarding the activities that they would like to participate in. Comments were also received that tea time was disorganised and that service users felt rushed. The manager is seeking to address this. The new cook is in the process of developing menus. Views have been sought of the people living at the home. It was generally found that people have requested ‘old fashioned’ ‘plain food’. Feedback was varied regarding the meals provided. Some people felt that overall the provision of meals had improved, although several complaints were made regarding a meal at the weekend where the meat was felt to be tough. This was discussed with the manager. The cook has sought to improve the choices available at teatime and has ensured that a choice of meals is always available for the cooked lunch. Lunch time was observed. Care staff served meals from a hot food trolley. Staff were wearing protective tabards and hats. Service users were able to have meals in the dining room or their room as they prefer. The choice was beef and vegetable pie or salmon fish cakes, with a choice of two types of Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 16 potato and vegetables. A further choice had been available to some service users. The food seen appeared well cooked and presented. Service users had a choice of hot or cold drinks with their meal, and a choice of desserts was available. Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 17 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 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints policy and has responded appropriately to issues raised. The home does not have appropriate policies relating to the protection of vulnerable adults or whistle blowing in place to safeguard people living at the home. The home has operated a robust recruitment procedure to ensure that service users are not put at risk through unsuitable staff being employed. EVIDENCE: The complaints procedure is displayed on the notice board in the hallway. This states that CSCI may be contacted at any time, and includes the contact details for The Commission. This procedure should be amended to state that complaints should be investigated within 28 days. There has been one complaint received by the home. The home has taken appropriate actions and responded within the given timescales. The home has Adult Abuse policy. This provides information on different types of abuse that can occur. The policy states that the home should investigate Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 18 any concerns. This does not reflect good practice. This was discussed with the manager during the inspection who agreed to obtain a copy of the recent safeguarding adult guidance produced by Somerset County Council. The whistle blowing policy could not be located. This must include details of external agencies that may be contacted, and be made available to all staff members. Some service users spoken with during the visit advised that they would be able to raise concerns with the manager or a senior member of staff at the home. The home has obtained two references, a POVA First check and an enhanced CRB disclosure prior to any member of staff commencing work at the home. Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally the home has been maintained to a good standard, however some areas require attention to ensure that service users are not placed at risk. Service users rooms have been personalised to reflect individual tastes and preferences. The home has been maintained to a good standard of cleanliness. EVIDENCE: All communal areas and some service user rooms were seen during this inspection. Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 20 New armchairs have been purchased for the lounges, and conservatory. Lounges appeared homely. The radiator had not been switched on in the conservatory meaning that it was too cold to sit in. One service user room has been re-decorated. A new carpet, bed linen and curtains have been purchased. There is new furniture within this room. One service user room seen was noted to be malodorous. This was discussed with the manager who advised that there is a plan in place to address this. The carpet within a further service users room has started to ridge and may pose a trip hazard. Some furniture in service user rooms is showing signs of wear and tear and requires replacement within the refurbishment programme for the home. Within the room of one service user who lives on the first floor, the window openings had not been restricted within their bedroom or en suite bathroom. This service user advised that as the radiator in their bathroom does not produce much heat, they had been given a plug in portable electric heater to use in there. This matter was discussed with the manager who agreed to take immediate action as these matters may pose a serious risk to the service user. Window openings on ground floor windows have not been restricted. A risk assessment should be completed in relation to the risk of someone entering the building or a service user going missing. A security risk assessment should be completed for the building as a whole. Hand washing facilities consisting of liquid soap, paper towels and footoperated bins have been provided for staff in all service user rooms. Radiators have not been guarded in hallways or communal rooms. There is a notice on the first floor advising service users to ‘take care and not to hold on the radiators’. This radiator was noted to be very hot, and may pose a serious risk of scalding to service users. The registered person must regularly monitor the temperature of unguarded radiators and take any appropriate action. It is common practice within care homes for older people for radiators to be guarded within hallways and communal areas due to the dependency levels of service users and the high risk of falls. The home has emergency lighting. It is recommended that this be tested on a monthly basis. Within the first floor bathroom the bath panel has been replaced and paint work repaired near to the toilet. Appropriate hand washing facilities had been provided. A tablet of soap had been left by the bath; these items may pose a risk of cross infection and must not be kept within communal areas. The laundry was clean and well organised. The washing machine has a sluice cycle and red alginate bags are available. There is a sign near the hand basin Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 21 advising that items should not be soaked. There was a commode pot containing a garment being soaked below this. The practice of soaking items poses a risk of cross infection and must cease. Appropriate hand washing facilities had been provided. It is recommended that a foot operated flip top bin is provided for staff close to the hand basin. Paintwork in some areas of the laundry has begun to flake and requires attention to ensure that this area can be thoroughly cleaned. The home had been maintained to a high standard of cleanliness. Service users confirmed that this is always the case. Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 22 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 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has operated a robust recruitment procedure to ensure suitable staff are employed. There was no evidence that newly appointed staff had been provided with induction training. This means that these staff members may not have been provided with the knowledge to safely undertake their role. EVIDENCE: Duty rotas evidenced that there is generally 6 care staff on duty during the morning, and 4 staffing during the afternoon on weekdays and 4 staff during the morning, and 3 staff during the afternoon at weekends. There is one waking and one sleep-in member of staff on duty at night. Domestic and catering staff are also employed. Some service users stated that sometimes there are not enough staff and that this results in them waiting longer to receive help from staff, and a lack of social activities Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 23 One staff member spoken with advised that there was a on-going programme of training, and that they planned to complete a moving and handling update, first aid training and food hygiene within forthcoming months. Two staff files were examined. It was found that the application form did not make it clear that two references were required, or that one must be from the last employer. This has been addressed on an updated employment form. It was found that two satisfactory references, a POVA first check and enhanced CRB disclosure had been obtained prior to a member of staff commencing employment at the home. Proof of identity had been obtained. There was not a photograph for one staff member. An interview record had been maintained. Newly appointed staff had been provided with a job description and given a copy of the General Social Care Council code of practice. There was no record of newly appointed staff receiving induction training, or completing manual handling, health and safety or first aid training. Two newly employed members of staff had not received fire safety training. The manager advised that they plan for all staff to complete induction training again, to ensure that all have covered basic areas. Advice was given regarding the Common Induction standards. The manager advised that they will download copies of the Induction pack from the Skills for Care website. Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 24 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): 31,32,33,34,35,36,37 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is effectively managed. The home has sought the views of the people living there, and is taking action to address the issues raised. Service users may be at risk from the failure to maintain fire safety records. Records relating to accidents and incidents have not been appropriately maintained. This means that events affecting service users cannot be effectively monitored and appropriate actions taken to minimise risk. The registered person has not developed appropriate policies and procedures to promote the health and safety of service users and staff at the home. Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 25 EVIDENCE: The manager is Paulene Coles. Ms Coles has been in post for three months. She has many years experience of providing care to older people and has applied to become the registered manager for the home. People living at the home are encouraged to express their views. Resident meetings are held. At the recent meeting the provision of activities and meals was discussed. Surveys had been sent to some service users, but the outcome of these had not been collated. Staff meetings are held. The manager has just started undertaking staff supervision. She advised that all staff have completed a self-appraisal and that formal supervision has taken place for a small number of staff members. There are plans to delegate supervision of some staff to senior staff within the team. The home displays appropriate Employers Liability insurance. The registration certificate had been displayed. The home will keep money securely for those service users that wish them to. Monies are held separately for each service user, and records maintained of all transactions. Three monies were checked and were found to tally with the records kept. Accident records are audited regularly. The member of staff undertaking this role is not a member of the care team. It would be more appropriate for the accident records to be audited by a staff member who has clinical knowledge and experience. As previously stated daily records for one service user evidenced that they had suffered a fall requiring attention from a paramedic, however an accident record had not been completed and CSCI was not notified of this incident. The home has a fire risk assessment. The fire safety policy must be updated to ensure that the home has an evacuation policy. The fire safety policy currently states that the sleep in member of staff should stay behind the door the their room, therefore this would leave only one member of staff to assist service users. The fire drill record was blank. There was no record of fire training for two newly employed members of staff. There was no record of the fire system or emergency lighting being serviced. Fire extinguishers have been serviced appropriately. Records evidenced that the fire alarm had been set off on four occasions due to problems with the sensors, however CSCI was only notified on of this twice. The registered person must ensure that CSCI is informed of all appropriate Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 26 incidents in accordance with Regulation 37 of the Care Home Regulations 2001. The passenger lift, electrical hardwiring and portable appliances have been tested appropriately. The hoist is now due to be serviced. Wheelchairs are checked regularly. Hot water temperature outlets had only been checked in communal bathrooms and not in service user rooms. This means that service users may be at risk of scalding from hot water temperatures within their en suite bathrooms. There was no information regarding the running to baths in service user rooms to reduce the risk of Legionella. Kitchen records were examined. A risk assessment had been completed by the cook and the manager, which is reviewed on a monthly basis. Generally the kitchen appeared cleaner, and better organised. The new cook has been completing the Safer Food, Better Business recording system. A number of foods within fridge and freezers had not been covered or dated. Hazardous substances had been stored securely. Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 27 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 3 2 X 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 3 3 3 3 2 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 1 1 Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? NA 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 OP7 Regulation 15 Requirement All amendments to care plans must be signed and dated. Where a service user can be reluctant to accept help in managing their personal care needs, or display aggressive behaviour, an appropriate plan must be developed so that staff may follow a consistent approach. 2. OP8 15 (1) Risk assessments must be completed in relation to the use of denture cleaning tablets, where appropriate. Falls risk assessments must be updated following a service user having a fall. 3. OP9 13 (2) To ensure that the home is able to audit medicines, a record must be made of all medicines received into the home and of those leaving for any reason. (Previous timescale of 26/10/07 not met) Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 29 Timescale for action 14/01/08 14/12/07 21/12/07 4. OP9 13 (2) All medicines cupboards must be affixed in accordance with current regulations. The registered person must an appropriate range of social activities. The registered person must ensure that a copy of the safeguarding adults policy is obtained, and that the protection of vulnerable adults policy is updated to reflect good practice. The registered person must develop a whistleblowing policy, that includes details of external agencies that may be contacted. The whistle blowing policy must be made available to staff members. 21/12/07 5. OP12 1 (2) [n] 25/01/08 6. OP18 13 (6) 14/01/08 7. OP18 13 (6) 14/01/08 8. OP24 16 (2) [c] The registered person must take 21/01/08 appropriate action to address the carpet within room 10 that has started to ridge and may pose a trip hazard. Furniture and soft furnishings that are showing signs of wear and tear must be replaced within the refurbishment programme for the home. The registered person must ensure that: • The conservatory is maintained to an appropriate temperature where service users may use this room. A risk assessment is completed in relation to unrestricted windows on Version 5.2 Page 30 9. OP24 16 (2) [c] 31/03/08 10. OP25 23 (2) [p] 25/01/08 • Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc the ground and first floor, and any appropriate actions taken. • The registered person must regularly monitor the temperature of unguarded radiators and take any appropriate action. 03/12/07 11. OP25 13 (4) [a] The registered person must ensure that electric portable heaters are not used in en suite bathrooms, and that these rooms are maintained to an appropriate temperature. Staff must not soak soiled items, as this practice may pose a risk of cross infection. The paintwork within the laundry must be repaired to ensure that this area remains easy to clean. A photograph must be obtained for each staff member. Newly appointed staff must be provided with induction training, and an appropriate record maintained. CSCI must be notified of all incident affecting the wellbeing of service users, in accordance with Regulation 37 of the Care Home Regulations 2001. Information regarding service users must be recorded in accordance with the Data Protection Act 1998. 12. OP26 13 (3) 21/12/07 13. OP26 13 (3) 25/01/08 14. 15. OP29 OP30 19 & Schedule 2. 18 (1) [c] 04/01/08 04/01/08 16. OP37 37 21/12/07 17. 18. OP38 OP38 17 & schedule 3. 23 (4) Accident records must be maintained. The registered person must DS0000070759.V355194.R01.S.doc 21/12/07 25/01/08 Version 5.2 Page 31 Northway House Residential Home Limited ensure that fire safety records are appropriately maintained. This will include: • Updating the fire safety policy to ensure that the home has an evacuation policy. Review of the fire safety policy in relation to the actions taken by sleep-in members of staff. Maintaining a record of fire drills. Maintaining a record of fire safety training for newly employed staff. Records of the fire system or emergency lighting being serviced. 04/01/08 • • • • 19. OP38 13 (4) [c] Hot water outlet temperatures must be tested in service user rooms. Records must be maintained of water being run from baths in en suite bathrooms to reduce the risk of Legionella. 20. OP38 13 (4) [c] Food stored within fridges and freezers must be covered and dated. 21/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 32 No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard OP2 OP16 OP19 OP25 Good Practice Recommendations It is recommended that the contract also include the number of the room to be occupied. This procedure should be amended to state that complaints should be investigated within 28 days. It is recommended that a security risk assessment is completed for the building. It is recommended that emergency lighting be tested on a monthly basis. It is recommended that a foot operated flip top bin is provided in the laundry. Staff should receive supervision at least six times a year. It is recommended that accident records be audited by a staff member who has clinical knowledge and experience. OP26 OP36 OP38 Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Northway House Residential Home Limited DS0000070759.V355194.R01.S.doc Version 5.2 Page 34 - 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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