Inspection on 31/05/06 for Northwick Grange

This inspection was carried out on 31st May 2006.

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

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

Other inspections for this house

Northwick Grange 21/05/07

Northwick Grange 02/03/06

Northwick Grange 20/06/05

Northwick Grange 30/11/04

Northwick Grange 08/06/04

Northwick Grange 09/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Northwick Grange 19 Old Northwick Lane Worcester Worcestershire WR3 7NB Lead Inspector Andrew Spearing-Brown Unannounced Inspection 10:30 31 May and 2nd June 2006 st 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 Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 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. Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Northwick Grange Address 19 Old Northwick Lane Worcester Worcestershire WR3 7NB 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) 01905 453916 Northwick Grange Limited Georgina Betty Moss Care Home 32 Category(ies) of Dementia - over 65 years of age (32), Old age, registration, with number not falling within any other category (32), of places Physical disability over 65 years of age (32) Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd March 2006 Brief Description of the Service: Northwick Grange is a Georgian house, situated in a residential area on the outskirts of Worcester. It was first registered in 1993, and is part of the Redwood Care Home group. The home is on three floors and has a stair lift in place. Northwick Grange provides personal care for a maximum of thirty- two older people who may have a physical disability and or a mental health need associated with the ageing process. A comfortable lounge and dining room are provided on the ground floor. Information gained from the pre inspection questionnaire received on the 18th May identified that fees at Northwick Grange currently range from £343 to £360 per week. Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector from the Worcester office of the Commission for Social Care Inspection (CSCI) carried out this inspection. The focus of inspections carried out by the CSCI is on the outcomes for people who use the service. As part of the overall inspection of the service offered at Northwick Grange two visits to the home were undertaken. The first visit to the home was unannounced while the second was arranged with the registered manager and was therefore announced. A total of about 9 ½ hours were spent in the home. The previous visit to Northwick Grange, which was unannounced, took place during early March 2006. This inspection takes into account information received by the CSCI since the previous inspection as well as the visits to the home. Prior to the visit a pre inspection questionnaire (PIQ) was posted to the registered manager requesting certain information. This document was completed and returned to the CSCI prior to the first visit to the home. In addition to the PIQ a number of questionnaires for residents, relatives and health care professionals were also sent to the home. A total of six residents questionnaires were returned, staff on behalf of residents compiled all of these, none highlighted any cause for concern. A number of questionnaires were left following the previous inspection in March 2006. The previous report was completed prior to these questionnaires coming back to the CSCI therefore they form part of this inspection report as information gleaned. A total of five questionnaires were returned including one from a Community Nurse. The CSCI received a letter of complement shortly before this inspection from a relative of a resident who recently died at Northwick Grange. The registered manager was on annual leave however came into work and was within the home throughout the process. The registered provider also attended and took part during some of the first visit. The key standards designated by the CSCI as well as the requirements and recommendations from the previous inspection were assessed. In addition to the manager discussions took place with the owner, the deputy manager, a senior carer and one carer. Discussions also took place with three residents plus brief discussions with a number of other residents. Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? Although shortfalls were identified in the management of medication it was evident that some areas raised as part of the previous inspection are now met. A new extractor fan is in place within the kitchen, the date by which time a new floor covering is to be in place within this area had not expired. Considerable improvement has taken place to remove a number of previously set requirements regarding infection control. Liquid soap and paper towels are now available throughout the home in communal facilities. Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 7 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. Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 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 Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 4. Standard 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of a thorough written assessment prior to admission results in the home having no evidence that care needs can be met. Staff receive training to assist them with knowledge and skills to meet care needs. EVIDENCE: A copy of both the Statement of Purpose and Service Users Guide were on display near to the lounge. Both documents were dated November 2005, although not fully assessed in was noted that they contained sufficient details to equipment residents and potential residents with information about the home and services provided. A blank contract was seen which showed that fees do not include dry cleaning, newspapers, hairdressing and taxi/escorts. The file of a recently admitted resident contained an initial assessment as well as a document entitled residents record. The residents record comprised of more details following the initial assessment document, together these documents are able to encapsulate sufficient information providing they are Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 10 used to their entirety. It was however disappointing to note that both documents were dated the same day as which the resident was admitted; therefore no evidence was in place that a representative from the home had made any assessment of need prior to admission to ensure that the home was able to meet identified care needs. The registered manager believed that an assessment had taken place beforehand but was not recorded. Northwick Grange is registered to care for 32 residents all of whom may have a diagnosed dementia type illness. A letter of confirmation regarding training booked as well as a training matrix demonstrated that the majority of staff have received training in dementia. Northwick Grange does not offer intermediate care. Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are not sufficiently or suitably up dated. These and other shortfalls not do give the required level of information required by staff to provide consistent care provision. The home has made progress with regard to the arrangements for administering medication, however shortfalls identified continue to potentially place residents at risk. EVIDENCE: Recent inspections to Northwick Grange have noted improvement in residents care plans. They are easy to read and person focused. A sheet entitled ‘Daily Routine’ – gives a brief pen picture of each resident containing information such as time of rising in the morning, bathing routine and hair care. A photograph is included within the care plan to afford easy recognition should it be needed. A representative sample of care plans where viewed as part of the inspection. Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 12 The daily records were generally insufficient in detail to demonstrate that care needs were met and that some recognition to individuality had taken place. Terms used included ‘ happy’ ‘ no worries’ and ‘in a good mood’. Daily records tend to be written at 11.00 am, in the majority of cases no further recording was made until 24 hours later. It was of concern that on one occasion a carer had recorded ‘ unwell – says feels okay – observe’ it was not evident from records that any observation had taken place nor any indication as to how the residents condition either improved or worsen during the course of the day. Documentation regarding bathing was insufficient to evidence that identified personal hygiene care needs are carried out. Records were available for staff to capture this information; these included the daily notes, an individual bathing record and bath temperature records. These records showed gaps and differed from each other. Although the lack of recording could not be disputed the registered manager was confident that the periods whereby it appeared residents went un-bathed were not a true record of actual practice. As residents would not be able to confirm the number of baths provided the home was unable to evidence that suitable bathing had taken place. The up dating of care plans was not sufficient in some cases. One care plan commenced in April 2006 was not reviewed until the 1st June. Another care plan although up dated during May was not reviewed or amended as necessary following a fall. No fall risk assessment was in place. The care plan in relation to a resident with a medical condition made no reference to the condition or some of the likely symptoms. Finally the care plan regarding a resident prone to chest infections was not up dated regarding pressure damage concerns. The records seen showed that medical attention is sought as needed. Visits from doctors and district nurses are recorded upon a professional visits sheet, which can usually be crossed referenced to the care plan Following the previous two inspection reports requirements were issued regarding the management and administration of medication. These requirements have been met at the subsequent inspection on both occasions. Despite meeting the previous requirements additional shortfalls were apparent as part of this inspection and therefore new requirements are issued which require immediate action. These requirements will be re assessed as part of a future inspection visit to the home. A number of gaps were evidenced upon both the current months Medication Administration Record (MAR) sheets as well as sheets from a previous month, which were also viewed. These gaps are where no signature to confirm administration of the item or a code to explain why it was omitted was in place. The MAR sheets allow for reasons why medication is omitted by means of different codes. The letter ‘O’ is the code for ‘other – define’, this code was used on a number of occasions however no definition was given. A previous Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 13 months MAR sheet showed that a resident was prescribed a course of 28 antibiotics, however the sheet contained 29 signatures. The sections regarding allergies and the booking in of medication on the MAR sheets were suitably completed. The storage of medication including controlled medication is in line with the required standard. At the time of the inspection only one resident was taking a controlled drug, the controlled drugs book was completed satisfactorily. Due to the unavailability of a triangle to assist in the counting of the number of drugs held a full audit was not undertaken. It was noted that one residents preferred form of address was on the care plan; the used of this name was check out with the resident concerned and was confirmed. Furthermore it was confirmed that the carrying out of some household tasks such as polishing were a positive choice, the arrangements in place matched the details within the care plan. From observations made and discussions with staff and residents privacy and dignity is upheld. Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While the social activities undertaken by residents needs to be improved to demonstrate how quality of life is maintained and enhanced, the meals provided are well received by the residents. EVIDENCE: Open visiting is in place whereby no restrictions exist. No visitors were seen within the home throughout this inspection. Links with the local community are limited. Information regarding residents access to records is displayed as is information regarding how to contact external advocates. Residents are able to bring into the care home their own personal possessions. Comments regarding the level of activity provided within the home were mixed. Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 15 Religious needs are met by means of ministers visiting from a nearby Church of England as well as a Methodist Church. A priest visits from a local Roman Catholic Church. Information regarding activities is available on a notice board. Each morning the activity is listed as ‘reading newspapers’. As morning newspapers are not provided by the home this is somewhat limiting. Staffing levels and the need to carry out personal care needs limit the availability of staff to carry out any meaningful event during the morning. Events are listed during the afternoon such as bingo, colouring, sing a long and quiz. The recorded number of residents who have taken part in these events is small (between 3 and 7) and therefore although these events may be suitable for a minority they may not be suitable for the majority. Activities involving staff on a one to one basis may be more suitable for some residents. The meaningfulness, structure and suitability of events within the home needs to be reviewed and evaluated in the future. Comments from residents consulted regarding the food available were positive. One resident stated ‘lovely dinners’. The meal served at lunchtime on the final visit of this inspection looked appetising. A choice was offered to residents regarding the meal as well as the type of drink available. One carer was seen visually demonstrating drinks on offer to a resident with a dementia type illness, this is good practice. One resident confirmed that a choice of drink is always given. Residents were offered a choice of cereal at breakfast although one resident stated ‘you should know’. Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 16 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 the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a complaints procedure in place. In addition staff have received training in the recognition of abuse, both of which should assist in safeguarding the interests of residents. EVIDENCE: The previous inspection report states that the complaints procedure outlines how a complaint will be dealt with by the home and that it sets out clear timescales for responding to a complaint. As the standard was assessed as met on that occasion the procedure was not read in full as part of this visit. It was however noted that the procedure was on display in the entrance hall as well as included within the Service Users Guide and Statement of Purpose. From information included within the pre-inspection questionnaire as well as in discussions with the registered manager it was established that the home has received no complaints since the last inspection. One questionnaire completed by a member of staff on behalf of a resident stated ‘very happy here – no complaints.’ In consultation with a number of residents they also confirmed that they had no complaints. One stated that she would ‘tell the head lady’ (referring to the registered manager) of any complaints or concerns. Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 17 The policy and procedure for the protection of vulnerable adults requires some amendments in that it does not make reference to the adult protection coordinator and mentions the NCSC (National Care Standards Commission) rather than the CSCI. Although the procedure needs amending it is evident that the registered persons take any allegations seriously and would refer any concerns to suitable agencies such as the CSCI, Adult protection, the Police and the Department of Health’s Protection of Vulnerable Adult (POVA) list. Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 18 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 the following standard(s): Standard 19, 21, 24, 25 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although some areas of the home are acceptable other areas are in need of repair or refurbishment in order to provide an environment that is homely and safe to live in. Infection control measures have improved to reduce the potential risk of cross infection. EVIDENCE: The previous two inspection reports have highlighted a number of shortfalls regarding the need for refurbishment around a number of areas of the home. Some carpeting in communal areas is in need of replacement namely the stairs and the corridor from the main lounge to the dining room. The floor in the kitchen also needs to be replaced although the previously set timescale has not yet been reached. Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 19 Some bedroom doors have suitable locks fitted while others do not. The registered provider intends to fit locks to bedrooms were the current occupant has requested a lock to be fitted. Care plans do state if a key is not requested. In order to meet the standard the facility to lock all bedroom doors to meet future needs should be provided. Locks were not checked on any bathrooms or toilets during this inspection. Previous inspection reports have made comments regarding the bathroom on the top floor and the need for it to be refurbished. The registered persons need to undertake a full review of bathing facilities to ensure that they are sufficient and suitable to meet current care needs of residents residing within Northwick Grange. The furniture supplied within the communal areas is of a satisfactory standard. Bedroom furniture is not in general to such a good standard. In many cases the current occupant owns some of the bedroom furniture within their bedroom although the inventory included with the care plan did not make this differential clear. One wardrobe was checked and was suitably secured to the wall to prevent accidental tipping over. The pillow on one bed was stained and was in need of changing. A small number of tins of paint and some personal items belonging to staff were in a lobby area near to the bedrooms reached via the kitchen area. This area requires improvement. The bedroom floor of one bedroom was changed to a vinyl covering while a resident occupied that room, in the event of another resident residing in that room a more suitable floor covering must be fitted. The bedroom door consists of some glass panelling and therefore compromises privacy as well as potentially allowing light from the lobby area into the room at nighttime; this must be addressed. The room contained a portable heater that was not secured to prevent it falling over and was lacking a suitable cover. The paintwork in this area is damaged and in need of painting. The registered provider stated that Environmental Health officers have not voiced any concern regarding the fact that this area is reached by means of entering the kitchen door and passing through a preparation area. A passageway to an exit in this area is also used as a smoking area. A notebook within the bathroom showed that the hot water temperature is consistently 43° C. A contract for a survey regarding the homes current standing in relation to any potential risk from Legionella is to be carried out. It was evident while looking around the home that it is likely that some pipe work has dead legs that can be a potential cause for concern. This inspection took place during a period of warm weather. The dining room and especially the corridor (has a glass roof) between the dining room and the main lounge were partially warm and not well ventilated. Although the Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 20 corridor area has a ceiling fan serious consideration needs to be given as to how to control extreme temperature levels within this area. Liquid soap and paper towels were available within all toilets and bathrooms viewed in line with local infection control procedures. The registered manager discussed the possibility of introducing antibacterial hand gel for staff to carry upon their person in order to further increase the infection control measures within the home. No offensive odours were noted at any time throughout the inspection. The sluice washing machine was reported to be new since the last inspection. Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An insufficient number of staff are on duty at certain times of the day. Recruitment procedures were found to have a short falling both of these can potentially place residents at risk. Staff training is sufficient by means of the events arranged. EVIDENCE: Staffing rotas were supplied to the CSCI prior to the inspection along with the pre inspection questionnaire. In addition the current weeks rota was viewed. The rota shows the role in which each member of staff is employed, for some persons who undertake different jobs such as both care and domestic they are named twice. Prior to the last inspection changes were made to ensure that an additional member of staff is on duty at 7.00 am to assist with getting residents up and dressed. This person converts to her other role as laundry assistant once residents are ready for breakfast. During the morning the rota demonstrated that four people are on duty however this figure could include the registered manager. Taking into account the care needs of residents as well as the layout of the home this figure is considered to be insufficient and should not include the registered manager who should be working supernumerary. Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 22 The laundry is staffed on weekday mornings once initial care duties are carried out. Four carers, including the deputy manager and assistant manager hold an NVQ (National Vocational Qualification) level 2. The assistant manager also holds a level 3 qualification. In addition two domestic members of staff who used to be carers and now work on care to cover holidays or staff shortages also both hold level 2 qualifications. Including the 2 domestics in the number of carers employed a total of 35 of carers are suitably qualified. The registered manager is aware that this currently falls short of the expectation that 50 of carers would have achieved a level 2 by the end of 2005. It is however anticipated that the 50 level will be exceeded by the end of 2006 as a further six carers are currently undertaking NVQ level 2 training. A file appertaining to a recently appointed member of staff was viewed. It was evident that an application form was in place however it did not give a full employment history. Evidence was held showing that clearance was obtained in relation to a check against the POVA (Protection of Vulnerable Adults) list before employment commenced. The address slip from the CRB (Criminal Records Bureau) was on file however this did not show the date upon which head office received the clearance. Although verbal references were taken before the commencement of employment written reference were not sought until the member of staff had started work. Two written reference are to be obtained before employment starts. Since the conclusion of this inspection a list of employees with the date upon which their CRB was received has arrived at the local office of the CSCI. Copies of a booklet issued a number of years ago by the General Social Care Council were available. Northwick Grange has no volunteers. The induction-training file of one recently appointed employee was viewed. The items to be covered during induction are extensive. It was evident that the induction process had got off to a reasonable start however a number of key components had not been covered including fire training. It is crucial that new members of staff have a basic understanding from the point of commencing duties of the procedures to be followed in the event of a fire. These procedures need to include how to sound the alarm, what procedures are in place to call emergency services and how to ensure that residents are free from immediate danger. Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 23 Despite the above comments the training matrix and comments from staff seen during the inspection demonstrated that the majority of staff have undertaken mandatory training. Staff who have not received mandatory training such as fire awareness must do so. Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is suitably qualified and has extensive experience in order to full fill her job. Quality monitoring and staff supervision systems although in place need to be improved. Some health and safety matters need addressing. EVIDENCE: Certificates showing the training undertaken by the registered manager were on display. These include the Registered Mangers Award, a NVQ (National Vocational Qualification) level 4. A certificate following the award of ‘Highly Commended in category nursing home carer of the year 1990’ presented to the registered manager prior to her current role by Age Concern was displayed. In discussions three residents spoke highly of the registered manager. Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 25 The Redwood group of homes has a system whereby 6 monthly audits provide feed back from residents, family and others such as doctors. These form the current Quality Assurance system. The responses from the most recent audit were reported as very positive with comments such as ‘very friendly’ ‘welcoming – feels like home’. Other methods of ensuring a full quality assurance programme need to be improved. The registered providers reports following monthly visits need to be completed and available to the CSCI. The registered manager stated that the home does not offer any system for the safe keeping of resident’s money. The registered manager is aware that staff should receive formal supervision at least six times per year. Supervision records indicated that some staff have received one supervision session during 2006 and therefore the frequency of these sessions is currently insufficient. A fire safety officer visited the home during June 2005; at the time of compiling this report the home was awaiting the report from the combined fire authority. The fire log showed that the fire alarm is tested on a weekly basis and in sequential order as necessary. As recorded upon the pre inspection questionnaire the registered manager was awaiting a certificate from head office regarding the testing of electrical hard wiring. A copy of this certificate should be forwarded to the Worcester office of the CSCI. Reference to the use of portable heaters and footrests on wheelchairs are made earlier within this report. Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 26 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 X 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X 2 2 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement A written assessment must be completed in detail, before the admission of any service user and in accordance with the requirements of Regulation 14 and Standard 3. (Previous timescales of 31/03/05, 20/06/05 and 03/03/06 not met – this requirement must now be fully met with out delay) 2. OP7 15 (1) Residents care plans and daily 02/06/06 notes must contain sufficient up to date detail to ensure that carers are able to meet identified care needs. 02/06/06 Residents records must be maintained to ensure that an accurate account of events is in place and that these are able to be cross referenced against other records. These events include recorded personal and health care needs such as bathing and pressure prevention. Timescale for action 02/06/06 3. OP7 OP8 15 (2) Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 28 4. OP7 15 (2) Care plans must be reviewed on a monthly basis or more frequently to reflect changing care needs. A suitable and up to date falls risk assessment must be maintained in relation to residents individual care needs. Accurate records must be maintained regarding medication administration within the care home using the correct coding. Suitable and meaningful activities must be identified and provided. The kitchen flooring must be replaced. (The time scale for meeting this requirement had not exceeded at the time of this inspection. The original time scale remains in place) 02/06/06 5. OP7 13 (4) 02/06/06 6. OP9 13 (2) 31/05/06 7. OP12 16 (2) 30/06/06 8. OP19 23 (2) 30/06/06 9. OP19 13 (4) 23 (2) (b) All areas of the home must be kept in good repair and good order. (Previous timescale of 31/08/05 not met – a new and extended timescale is given) 31/08/06 10. OP19 13 The programme underway to fit thermostatic valves on all wash hand basins must continue. The scheduling must be defined by means of risk assessment. DS0000018666.V293673.R01.S.doc 31/08/06 Northwick Grange Version 5.1 Page 29 11. OP24 23 (2) (b) Residents must be provided with single action locks on their bedroom doors to provide privacy and means of escape in the event of a fire. (Previous timescale of 31/03/05 and 31/08/05 not met – a new timescale is given for full compliance). 31/08/06 11. OP24 16(2)(c) All fatigued items of bedroom furnishing must be replaced. (Previous timescale of 31/03/05 not met). 31/08/06 12. OP24 16(2)(c) Fatigued floor coverings must be replaced. (Previous timescale of 31/03/05 not met). 31/07/06 13. OP24 23 (2) (e) In order to provide private accommodation the bedroom door identified must have the glass sections replaced. A full risk assessment must be undertaken regarding the heat build up in the passageway between the lounge and dining room with suitable action taken to reduce the risks identified. If portable heaters have to be used they must be fully risk assessed and both secured and covered. Staffing levels at the home must be reviewed, to ensure service users needs are effectively met at all times. 30/06/06 14. OP25 23 (2) (p) 02/06/06 15. OP25 13 (4) 30/06/06 16. OP27 18 (1) 02/06/06 Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 30 17. OP29 19 Schedule 2 Two written references must be obtained prior to staff commencing duties. As part of the homes quality assurance the registered provider must undertake monthly visits and prepare a written report in accordance with the regulation. The registered manager must ensure that all carers receive formal supervision at least six times per year covering 1. all aspects of practice 2. philosophy of care in the home 3. and career development needs. The most recent Legionella risk assessment must be forwarded to the CSCI, along with details of any work undertaken arising from the risk assessment. (This standard was not assessed as part of the inspection carried out on 20th June 2005. The timeframe previously set remains - this requirement will therefore be re- assessed as part of a future inspection). 02/06/06 18. OP33 26 31/07/06 19. OP36 18 (2) 31/07/06 20. OP38 13(4)(a) (c) 31/07/06 Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 31 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations The registered manager should take suitable acting to ensure that controlled medication can be counted without having to empty the contents on to a paper towel. Although evident that the registered persons have a good knowledge of the action to be taken in relation to reporting matters of either actual or alleged abuse the procedure should be amended to include reference to the CSCI and the adult abuse coordinator. It is strongly recommended that as a further infection control method staff are issued with anti bacterial hand gel. 2. OP18 3. OP26 Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 32 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Northwick Grange DS0000018666.V293673.R01.S.doc Version 5.1 Page 33 - 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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