Inspection on 19/09/05 for Northwood

This inspection was carried out on 19th September 2005.

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

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

Other inspections for this house

Northwood 19/06/07

Northwood 12/09/06

Northwood 03/05/05

Northwood 24/06/04

Similar services:

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Henry Nihill House

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

CARE HOMES FOR OLDER PEOPLE Northwood 24 Gloucester Road New Barnet Hertfordshire EN5 1RZ Lead Inspector Anthony Lewis Unannounced Inspection 19th September 2005 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 Northwood DS0000010507.V249298.R01.S.doc Version 5.0 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. Northwood DS0000010507.V249298.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Northwood Address 24 Gloucester Road New Barnet Hertfordshire EN5 1RZ 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) 020 8440 5853 020 8440 5853 Peter Michael Trainor Mrs Catherine Trainor Mrs Catherine Trainor Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Northwood DS0000010507.V249298.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specified service user who has dementia may remain accommodated in the home. The home must advise the regulating authority at such times as the specified service user vacates the home. 3rd May 2005 Date of last inspection Brief Description of the Service: Northwood care home is located in a residential part of New Barnet a short walk from New Barnet train station, High Barnet underground station, local shops and bus services. The home is registered to provide residential support and care for up to seventeen older people, not falling into any other category. The registered providers are Mr Peter Trainor and Mrs Catherine Trainor. Mrs Trainor is also the registered manager. The accommodation is provided on two floors. The first floor is accessible to residents, who need mobility assistance, by a stair lift. There is one double bedroom on the ground floor, which is shared by two residents. All other residents have a single bedroom. There is a comfortable lounge and dining room and a large conservatory. The front and back gardens are maintained by a resident and a gardener. The front of the premises has off street parking for several vehicles. The home is staffed with a minimum of two care workers, one domestic worker, a cook and the manager, on the early shift. On the late shift, there are at least two care staff on duty. At night, there are two staff on duty, one wakenight and one sleep-in. Northwood DS0000010507.V249298.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on Monday 19th September 2005 at 9.30am and was completed at 4.20pm. The registered manager was available throughout the inspection process and was very helpful and accommodating. To gather information for this inspection, two residents were spoken to formally and five informally. Two relatives were spoken to informally. Three staff members were spoken to formally in the office. Five resident and five staff files were viewed along with various other records and certificates. A tour of the home was conducted with the registered manager. Seven requirements were made at this inspection and two recommendations. What the service does well: What has improved since the last inspection? What they could do better: The statement of purpose and service users guide must be updated to reflect the present situation in the home. Residents, their family or representative must be involved in drawing up and reviewing their care plans. Staff must ensure that all offensive odours are eradicated from the home and that they are trained to support residents who need continence management. In order to ensure that residents are being protected by the homes recruitment procedures, all staff must have a recent photograph in their file. So that they can fully meet the needs of the residents, all staff must receive sufficient training. Staff must receive regular formal supervision to ensure that their personal development is monitored and to ensure that senior staff are supporting them. Please contact the provider for advice of actions taken in response to this Northwood DS0000010507.V249298.R01.S.doc Version 5.0 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Northwood DS0000010507.V249298.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Northwood DS0000010507.V249298.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 6. The registered providers are not ensuring that prospective residents to the home, their family or representative, are provided with accurate information to make an informed choice. EVIDENCE: Whilst viewing the statement of purpose and service users guide, it was noticed that some of the information was inaccurate. For instant the Commission’s old name National Care Standards Commission (NCSC), is being used instead of Commission for Social Care Inspection (CSCI). In addition, the statement of purpose described the home has having a deputy manager and an administration assistant, which is not true. Both the statement of purpose and service users guide must be reviewed and updated to reflect the present situation in the home. This was a requirement at the previous inspection. This requirement is revised and restated. Each resident was seen to have a copy of their contract with the home in their file. Northwood DS0000010507.V249298.R01.S.doc Version 5.0 Page 9 The home does not take referrals for residents on intermediate care neither do they take unplanned admissions. Northwood DS0000010507.V249298.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Residents are confident that the staff team can meet their health and personal care needs and that the staff will support them in a caring and professional manner at all times. However, the registered manager is not ensuring that residents are being involved in all aspect of their care needs. EVIDENCE: Although each resident has comprehensive care plans drawn up and the care plans are reviewed regularly, there is no evidence that residents are involved in the drawing up process and the reviewing of their care plans. A requirement is made in regards to this. Each resident has a health care plan, which contains information regarding the health care that they will receive. Resident’s files showed that health care appointments were being made and attended. There was also evidence when the General Practitioner GP comes to the home and the district nurse has a form that she fills in whenever she visits the home. Northwood DS0000010507.V249298.R01.S.doc Version 5.0 Page 11 None of the residents self medicate. The Medication Administration Record (MAR) sheets were viewed and is being filled in correctly by all staff. Three residents were spoken to. All said that the staff treat them with a lot of respect. Two family members were also spoken and to both said that their relative is always treated with respect by all of the staff. Staff were indirectly observed interacting with residents in a caring and professional manner. Prior to touring the home, the registered manager was witnessed asking residents for permission to go into their bedroom. Northwood DS0000010507.V249298.R01.S.doc Version 5.0 Page 12 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): 12, 13 and 15. Residents are confident that the home will provide them with and support them in accessing appropriate social activities and that they will be able to choose what activities they will engage in. EVIDENCE: The notice board in the dining room contains information regarding entertainment that the home provides. Residents spoken to said that they were happy with the entertainment that the home provides. One resident said that she enjoys tending to the home’s garden and does so on a regular basis. On the day of the inspection, a number of relatives visited the home. A relative, who was visiting her mother, stated that her mother is happy staying in the home most days and was not interested in going out into the community. The registered manager stated that many relatives and friends visit the home, especially at weekends. Residents spoken to said that they enjoy the meals that the home provides. The home’s cook was spoken to and has a good understanding of the needs of the residents in relations to appropriate meals and dietary needs. Lunch was taken with residents. The meal was well prepared and residents said that they enjoyed the meal. One residents said that she looks forward to the meals. Northwood DS0000010507.V249298.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18. Residents are confident that the home’s policies and procedures and the training that staff receive will protect them from all forms of abuse and that any complaints that they make will be taken seriously and acted upon. EVIDENCE: The home has a comprehensive complaint policy and procedure. Residents who wish to make a complaint can find information on the procedure in the office and on various walls throughout the home. The home has a complaints file and the last recorded complaint was on 9th June 2003. The reasons for no complaints being recorded for the past two years were discussed with the registered manager. A recommendation regarding this has been made. Many of the resident’s family members are involved in their care and visit them at the home regularly. The registered manager stated that residents, who wished to vote, were supported by staff to do so in the May general election. The three members of staff spoken to stated that they had undertaken the Protection of Vulnerable Adults (POVA) training. Some certificates of the training were seen in some staff files. Northwood DS0000010507.V249298.R01.S.doc Version 5.0 Page 14 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): 19, 20and 26. The staff have ensured that all areas of the home are kept clean, tidy and safe and that residents are made as comfortable as possible. However, the staff are not ensuring that all areas of the home are kept free from offensive odours. EVIDENCE: On touring the home, all areas were clean and tidy and reasonably decorated. The registered manager stated that some of the carpets in the home would be replaced in the near future. An invoice for the re-carpeting was seen in the office. Communal areas such as the lounge and dining room are all well maintained. Residents spoken to said that the home is comfortable. The garden is well maintained by the gardener and one resident. Whilst touring the home, it was noticed that three bedrooms had a strong smell of urine. The registered manager explained that this was due to the residents. She went on to say that the carpets in the identified bedrooms would be replaced with suitable material. The need for all staff to be trained in Northwood DS0000010507.V249298.R01.S.doc Version 5.0 Page 15 continence management was also discussed. A requirement is made that the registered persons ensure that the home is kept free of offensive odours. Another requirement is made that all staff are trained in supporting residents who are incontinent. Northwood DS0000010507.V249298.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): 27, 29 and 30. The registered persons are not ensuring that residents are protected by the home’s recruitment process in relation to obtaining all of the relevant information on each member of staff and although staff are receiving more training some staff have not received sufficient training. EVIDENCE: Three members of the staff team were spoken to, all had a good knowledge of the residents and their associated care needs. The staff rota indicated that there are usually three staff on the early shift and two/three staff on the late shift. One resident said that she felt that there are enough staff on duty each shift to meet her needs. Five staff files were viewed and although they contained much of the information set out in Schedule 2 and 4 of the Care Homes Regulation, four were found to have no photograph of the member of staff, which was a requirement at the previous inspection. This requirement is restated. One member of staff said that she has completed her National Vocational Qualification NVQ2 and is awaiting her certificate and is now undertaking her NVQ3. The most recent member of staff, who commenced working in the home in March 2005, said that she would be starting her NVQ2 in October 2005. She went on to say that the home was very caring. Northwood DS0000010507.V249298.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 34, 35, 36 and 38. Residents are confident that their finances are being handled appropriately and that policies and procedures are in place to ensure that their interests are safeguarded. They are also confident that their safety is being taken seriously. However, the registered manager is not ensuring that the staff are adequately supported. EVIDENCE: The registered manager ensures that all residents are given information on the home’s fees prior to admission and on admission. Information was seen in resident’s files regarding the fees that they are charged. There was also information contained in the home’s financial records. The registered manager stated that the accountant has responsibility for the home’s finances and that relatives or an appointed person such as a solicitor has complete control of the resident’s finances. Northwood DS0000010507.V249298.R01.S.doc Version 5.0 Page 18 Although staff files indicate that staff are receiving supervision, there is no consistency. Some staff have not received any supervision this year or for more than six months. A requirement was made in relations to this at the previous inspection that all staff receives regular supervision. This requirement is restated. The home has a fire procedure manual and various fire tests, which are up to date, with tests carried out regularly. The London Fire and Emergency Planning Authority (LFEPA) inspected the home on 22nd May 2000 and made no requirements. The registered manager is making arrangements for the next LFEPA visit. All other certificates and records were seen to be in order and up to date. Northwood DS0000010507.V249298.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 3 1 X 3 Northwood DS0000010507.V249298.R01.S.doc Version 5.0 Page 20 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 OP1 Regulation 4(2)5(1a, f) 2(a,b) Requirement The registered persons must ensure that the statement of purpose and service users guide are reviewed and updated to reflect the present situation in the home and that a copy of each is forwarded to the Commission. (Timescale of 10/06/05 not met). This requirement is revised and restated. The registered persons must ensure that residents, their family or representative are involved in the drawing up of their care plans. (Timescale of 10/06/05 not met). This requirement is restated. The registered persons must ensure that the home is kept free from any offensive odours. The registered persons must ensure that all staff are trained in supporting residents who need continence management. The registered persons must ensure that there is a current photograph of each member of staff in their file. (Timescale of DS0000010507.V249298.R01.S.doc Timescale for action 28/10/05 2 OP7 15(2)(c) (d) 25/11/05 3 4 OP26 OP26 16(k) 18(1)(i) 23/12/05 23/12/05 5 OP29 19(1b,i) Sch 2 28/10/05 Northwood Version 5.0 Page 21 6 OP30 18(1)(c) (i) 7 OP36 18(2) 10/06/05 not met). This requirement is restated. The registered persons must ensure that all staff working in the home receives appropriate training for the work that they perform and that a copy of their certificates are kept in their file for inspection. (Timescale of 29/07/05 not met). This requirement is restated. The registered persons must ensure that all staff working in the home receives formal supervision at least six times a year and the content of the supervision is recorded. (Timescale of 10/06/05 not met). This requirement is restated. 23/12/05 23/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP16 Good Practice Recommendations It is recommended that the registered providers ensure that all complaints, are recorded and the appropriate action is taken, no matter how trivial the complaint or whether the complaint is sorted out immediately, the registered persons must ensure that the complaints policy and procedures are reiterated to all staff. It is recommended that the registered providers ensure that the staffing of the home is reviewed with a view to appointing a deputy manager or two senior care workers to ensure that there is always a senior member of staff on duty seven days a week on the early and late shifts and to ensure continuity of responsibility in the absence of the DS0000010507.V249298.R01.S.doc Version 5.0 Page 22 2 OP27 Northwood registered manager. Northwood DS0000010507.V249298.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Northwood DS0000010507.V249298.R01.S.doc Version 5.0 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!