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Inspection on 11/04/06 for Noss Mayo Residential Home

Also see our care home review for Noss Mayo Residential Home for more information

This inspection was carried out on 11th April 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents are cared for in a safe, homely environment by staff who are aware of their needs. People who use the service are happy with the care they receive.

What has improved since the last inspection?

A new staff call system has been installed in the care home.

What the care home could do better:

The home has not followed the recruitment policy which ensures staff are only employed after all objects set out in the care home regulations have been made. This is the fourth report in which this has been identified as a requirement since June 2005. The staff must ensure that they follow up the infection control policy of a care home. All staff must receive supervision in accordance with the National Minimum Standards. The inspection identified that staff were experiencing difficulty responding to the needs of the residents during the busy period in the morning.

CARE HOMES FOR OLDER PEOPLE Noss Mayo Residential Home 2 High Street Burgh Le Marsh Skegness Lincs PE24 5DY Lead Inspector Mr Ken Hague Unannounced Inspection 11th April 2006 07.50 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 Noss Mayo Residential Home DS0000044376.V288764.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. Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Noss Mayo Residential Home Address 2 High Street Burgh Le Marsh Skegness Lincs PE24 5DY 01754 810729 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) Mr Parbat Chana Kadchha Mrs Shanta Kadchha Care Home 14 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (13) of places Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registration for 1 DE(E) placement is on a named basis only. Date of last inspection Brief Description of the Service: Noss Mayo is a detached listed property, which was formally a vicarage. It is set in its own grounds, with a large garden to the rear and a car park at the front of the premises. The home is set back from the main road near the centre of the village of Burgh-le-Marsh approximately six miles from the seaside resort of Skegness. The home is registered to provide care for thirteen service users over the age of 65 who require personal care and one place for the category of MD (Mental Disorder). Service users are accommodated in six single and four double rooms on the ground and first floor, the latter being reached by the use of a stair lift. The Home is owned by Mr Parbat C Kadchha and Mrs Shanta Kadchha. Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place between 7.50am and 2.00pm. The main method of inspection used is called case tracking which involved selecting four residents and tracking the care they receive through the checking of their records, discussion with them and care staff and observation of care practices. A tour of the premises was conducted and care records were inspected. Three members of staff were formally interviewed and two spoken to informally. Four residents were interviewed and a discussion held with a relative. What the service does well: What has improved since the last inspection? 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. Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 Page 6 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 Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 Page 7 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): 1,3 & 6 There are satisfactory procedures for the introduction and assessment of people to the service, ensuring that care needs are met. Residents are happy with the care provided. EVIDENCE: Residents can view the homes statement of purpose which sets out the resources of the home to establish whether there needs can be met by the care home. New residents are encouraged to visit prior to making any longterm decision to stay at the care home. The individual files of residents being case tracked contained a full assessment carried out prior to them coming to stay at the care home. The home does not provide a specialised intermediate care service. Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 Page 8 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): 7,8,9,10 &11 The individual health care needs of residents are identified by the home and are met using community healthcare services. Medication is being stored and administrated in accordance with the National Minimum Standards. The home protects the dignity and rights of all residents. There are procedures in place to ensure that the wishes of the residents are respected after their death. EVIDENCE: There were four files inspected as part of the case tracking process. They all contained details of the identified health care needs of each resident. The management of each need was set out in the individual care plan. The manager was advised to ensure that care plans set out in detail how the healthcare needs were to be met and managed. Although all of the care plans met the National Minimum Standards there was a tendency to generalise statements on assessments. Care plans contained a list of potential needs where a need is identified the statement is highlighted or circled. The space within this form to expand on information demonstrating how that need was to be met and managed was not always completed. The management of identified need should relate to the specific need of that one resident. The inspection of care records and medication records provided evidence that the home is following it’s medication policy. Staff confirmed they had received training in the administration of medication. Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 Page 9 The acting manager provided evidence that training has been given and that future training has been planned with boots to ensure staff are competent in this area. Observations of care being provided to residents, the formal interviews in discussion with staff and comments from a relative visiting the home provided evidence that staff treat residents with dignity and respect. The Inspector observed staff providing personal care to two residents. They spoke in a sensitive quiet way reassured residents while providing care.They listened to what the residents said and responded to all requests for help. The individual files of the residents inspected all contained details of the wishes of the residents in respect of the action to be taken when they die. Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 Page 10 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): 12,13,14 &15 The home provides a range of leisure and social activities. Contact with relatives and friends is encouraged. The home provides a menu, which meets the dietary need’s of residents and offers choice. EVIDENCE: The menu was inspected and found to offer a choice for all residents. The cook confirmed that food is provided as indicated on the homes menu. All residents are consulted on a daily basis and asked to select their choice of menu the day. This is recorded and the records were seen by the Inspector. Residents confirmed that choice is offered. The special dietary needs of residents are recorded on their care records. The staff stated that relatives are encouraged to visit the home. The Inspector observed relatives visiting during his inspection. They were seen to be made welcome by staff. In formal interviews staff stated that activities were offered to all residents. A resident spoken to as part of this inspection confirmed that she visited the home on a daily basis and said staff had made her very welcome. Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 Page 11 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 & 18 The homes has policies and procedures in place to ensure that residents are protected from any possible abuse. Staff have been trained in the recognition and management of potential abuse situations. Residents are able to raise concerns or complaints with staff and the management of the home. EVIDENCE: Staff spoken to had a good understanding of how to protect residents from abuse and there was evidence that adult protection training had been provided in December 2005/January 2006. Lincolnshire County Council Social Services investigated a complaint in 2005 relating to care practice. There was evidence found on the failure to provide appropriate care to one resident on one occasion. The acting manager stated that the Social Services Department’s have made two visits since and that they are now satisfied with the care practice within the care home. There has been no other complaints received by the home or the Commission for Social Care Inspection since the last inspection. Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 Page 12 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): 19,20,21,23,24, 26 & 27 Residents live in a comfortable, homely, environment with a choice of communal areas and personalised bedrooms. The infection control policy of the home is not being followed by staff. The failure to follow this policy does put residents at risk. The home is not consistently being kept clean and tidy. EVIDENCE: The care home requires a great deal of maintenance. The rooms are tired with paper hanging off ceilings and walls. The carpet areas in the home required cleaning at the time the Inspector toured the home. One bathroom floor was sticky and dirty. A storage area in the kitchen was dirty. Two areas in the home did not smell fresh. Laundry had not been collected. The breakfast area was untidy and tables had not been cleaned and emptied. A bolt was fitted to a bathroom door which would allow a resident to lock the door and deny access to staff from the outside in event of emergency. The acting manager agreed that this would be removed. A bin in the lounge area contained stale cigarettes and uneaten food. A new nurse call system has been fitted since the last inspection. One bedroom being used for respite care was fitted with a hospital bed. This had been on loan to the last resident who had recently passed away. Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 Page 13 This type of bed should not be used for a resident taking respite care. Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 Page 14 Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 Page 15 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 & 30 The proprietors cannot demonstrate that there are sufficient staff on duty to meet the needs of all residents at all times. Staff are not being provided with supervision in accordance with the National Minimum Standards. Training is however being provided for staff which includes core training and specialised training. The recruitment policy for the home is not being followed. EVIDENCE: Observations made during this inspection provided evidence that staff were expected to prepare breakfast, serve breakfast, assist residents to get up and wash and dress, administer medication, cleaning some areas of the care home, issue and collect laundry and change beds. This work is carried out between the hours of 7:30 a.m. and 10:30 a.m. Staff stated there are three residents who will need two carers to assist them with their personal care. One resident needs to be moved using a hoist and this requires two members of staff. All staff spoken to on this inspection stated there was not sufficient time allowed to carry out all of its task. Staff stated that as the demands on them for time was so great they had not time to read care plans and therefore they were not used as a working document. The formal interviews with staff provided evidence that some information relating to their personal needs were not known to staff but were recorded in care plans. This related to medical conditions and allergies. The Inspector has had discussions with the proprietor on several occasions regarding the employment of the cleaner. The acting manager stated that the cleaner has recently been employed to carry out 2/3 days work per week. The home was not clean and tidy on the day of this inspection. It did not smell fresh and was not clean. There were items such as pads and paper on floors. Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 Page 16 An inspection of the kitchen provided further evidence regarding the lack of staffing hours. Working surfaces and the floor were dirty. The working surfaces were covered with dirty containers, utensils were not washed and there were dirty pots. There were two containers on the top of the cooker containing frozen food which was defrosting for the dinner. Staff stated that this food will not defrost within a safe period to be cooked by lunchtime. A member of staff had to ring the cook to ask her to make alternative arrangements for food. A pan on the cooker contained frozen meat again defrosting for lunch. All the frozen food was left uncovered. The window next to the cooker was wide open. The acting manager stated the member of staff who had left the kitchen with food uncovered and the kitchen in a dirty condition had been offered food hygiene training, but declined to take the course. She stated she would be offered training in the future. A member of the public who visits the home on a regular basis stated it was very busy at breakfast time. A resident complained that it took a long time for staff to respond to the call bell in the morning. Although they stated staff are very kind but are just too busy. The proprietor is not following the recruitment policy set out in the procedures manual. One staff members file contained only one reference. A second file for a new member of staff contained one reference from their last employer and a second reference which was handwritten and was several years old. This had been brought in by the member of staff, not requested by the home as required by the Care Home Regulations. The formal discussions with the acting manager, members of staff and the inspection of training records confirmed that training was being provided appropriately. Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 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): 31,33,35,36 & 38 The home’s policies and procedures ensure that residents’ finances are safeguarded. Staff are being provided with training including specialised courses. Staff supervision is not being provided in accordance with the National Minimum Standards. The infection control policy of the home is not being followed. Residents could therefore be placed at risk. There is no registered manager in post. EVIDENCE: An acting manager, who is to apply to the Commission for Social Care Inspection to become the registered manager, runs the home on a daily basis. Staff stated that she is approachable and committed to improving standards within the care home. The financial records for the management of individual resident’s finance were viewed as part of this inspection. These records are being managed in accordance with the National Minimum Standards. Staff stated that they had not been provided with supervision in accordance with the National Minimum Standards. The acting manager confirmed this to be the case. Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 Page 18 The evidence for the environmental standards and staffing standards support the Inspectors judgement that the infection control policy of the home was not being followed on the day of this inspection. The acting manager does not dispute this statement. Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 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 3 3 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 X 3 3 X 2 STAFFING Standard No Score 27 2 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 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 OP29 Regulation 19-1 Requirement The recruiment policy and its implementation must be robust to protect service users Supervision arrangements must be put in place for all staff identified at previous inspection The care Home must be kept clean and tidy and free from any odour the proprietor must employ staff in sufficient numbers who have appropriate training to meet the needs all residents. staff must follow the infection control policy of the care home. Timescale for action 20/05/06 2 OP36 18-2 28/05/06 3 4 OP26 OP27 23 18-1 28/05/06 28/05/06 5 OP38 13-3 28/05/06 Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Noss Mayo Residential Home DS0000044376.V288764.R01.S.doc Version 5.1 Page 23 - 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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