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Inspection on 26/09/07 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 26th September 2007.

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.

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

The home provides a comfortable, environment for people to live in. Residents have care plans, which enables staff to know how residents needs are to be met. Staff, are trained and supported by the acting manager and have a knowledge of residents needs. The home has established a good working relationship with the community health care teams and local GPs.

What has improved since the last inspection?

There was evidence of improved teamwork since the last key inspection. Staff feel supported and are more involved in care planning. The environment of the care home has improved and has been personalised. Housekeeping standards have improved. The majority of the requirements identified at the last key inspection have been met. Assessments are carried out before residents are admitted. All residents were found to have care plans. The medication policy the care home is being followed. Staff have been trained to protect residents from any possible abuse and to ensure they can meet the identified needs of each resident. Fire drills and training are now taken place.

What the care home could do better:

Care plans are not personalised which makes it difficult for staff to understand how residents prefer their care to be delivered. Plans need to define in more detail how any identified need of the resident is being met. Their likes and dislikes also need to be recorded in care plans. The review of care plans must be recorded in more detail and when needs have changed a new care plan should be written. All staff must receive formal supervision. The home has failed to address the issue of the disposal of clinical waste. This was a requirement at the last inspection and clinical waste is not being disposed of in a safe and appropriate manner. The acting manager has been in post for almost a year she should apply to become formally the registered manager of the care home.

CARE HOMES FOR OLDER PEOPLE Noss Mayo Residential Home 2 High Street Burgh Le Marsh Skegness Lincs PE24 5DY Lead Inspector Ken Hague Unannounced Inspection 26th September 2007 10:00 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.V351575.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 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 vacant post 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.V351575.R01.S.doc Version 5.2 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 5th April 2007 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. Mr Parbat C Kadchha and Mrs Shanta Kadchha own the Home. At the time of the inspection the home confirmed that the weekly fees ranged from £350 - £390 depending on the residents assessed needs. Additional charges are made for services such as chiropody, hairdressing and toiletries. Information about these costs as well as the day-to-day operation of the home, including a copy of the last inspection report, can be found in the reception area or from the home’s office. The home has a statement of purpose and service user guide, which sets out resources and services offered, by the care home. These documents are made available to all new potential residents. Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 6 hours. The acting manager and proprietors were provided with feedback at the end of the inspection. The main method of inspection used was called ‘case tracking’ which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them and the staff, and where more appropriate observation of interaction between staff and residents and related care practices. A sample of care records was inspected. A member of staff was interviewed and the opinions of residents were sought. An (AQAA) Annual Quality Assurance Assessment was not completed by the care home, as the time period from scheduling this inspection to the site visit was too short for this to happen. This is a self- assessment document completed by the providers of the care home. It sets out evidence from the provider to demonstrate that they are meeting the Care Home Regulations. It is normal procedure to obtain written feedback from residents prior to the site visit using a document called “have your say”. This document sets out a number of questions for residents to answer. In the case of this key inspection it was not possible to send out these documents within set timescales. The opinions of the residents were sought however during discussions held at the site visit. Their views are reflected within this report. What the service does well: What has improved since the last inspection? There was evidence of improved teamwork since the last key inspection. Staff feel supported and are more involved in care planning. The environment of the care home has improved and has been personalised. Housekeeping standards have improved. The majority of the requirements identified at the last key inspection have been met. Assessments are carried out before residents are admitted. All residents were found to have care plans. The medication policy the care home Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 Page 6 is being followed. Staff have been trained to protect residents from any possible abuse and to ensure they can meet the identified needs of each resident. Fire drills and training are now taken place. 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. The summary of this inspection report can be made available in other formats on request. Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 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 Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are procedures in place which are used for the assessment of new residents to the service. This ensures that all of their personal care needs, health care and social needs are identified and met. EVIDENCE: The care records of three residents were studied. They all contained a full assessment carried out prior to the resident being admitted to the care home. Details of medication were recorded. Risk assessments had been carried out. If a need was identified the management strategy was included on the resident’s care plan. Assessments were not detailed and although they identified the current residents needs more detailed assessments will be necessary for future residents who have more complex needs. A dedicated intermediate care service is not provided by the home Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 Page 9 Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 & 10 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Care plans identify need but do not provide detailed care instructions for staff to ensure they provide appropriate care. Residents’ health needs are recoded on care plans so these needs should be met. Staff are trainined to be aware of the importance of respecting residents privicy and dignity. EVIDENCE: All three residents being case tracked had a care plan on their individual care records. The care plans recorded the identified needs of each individual resident and how these were to be met. Risk assessments were in place, which included the management of any identified risk. The care plans did not however instruct staff how to meet identified need in detail. Neither were the care plans personalised to include the choices and wishes of individual residents. Care records therefore did not demonstrate that the homes assessment and care planning practice would ensure a resident admitted with complex needs would have had their needs fully identified and recorded. This could result in unmet need. Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 Page 11 The home records identified need by highlighted areas on assessment form for example needs help with mobility. The form does not explain in detail what the mobility problem is, how is it resolved or how many staff are required to carry out this task. Care plans have been reviewed but when a change was identified details of the change had not been consistently recorded. The home does not consistently demonstrate the involvement of the residents in the review of their care plans. Health needs are recorded on individual care plans care records demonstrate that these needs are being met. Residents confirmed in discussions that their health care needs including chiropody eye and dental care are being met by the care home. The medication policy is followed in respect of the administration and storage of medication. There was no evidence that residents are offered the opportunity to self-medicate if appropriate. However there are lockable facilities provided in bedrooms for residents who could self-medicate Discussions with residents and staff as well as observations provided evidence that the dignity and privacy of residents is being respected at all times. Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of activities are provided for residents which enables them to have an active and interesting social life. The homes menu offer choices and meets the dietary needs of residents. Relatives and friends are encouraged to visit and maintaining contact with residents which allows links to the community to be maintained. EVIDENCE: Residents stated that they are allowed to decide their own lifestyle, which includes choices of activities. The manager produced a list of activities, which take place within the care home. She stated that there are some set activities but in addition one-to-one activities are often arranged. Board games are organised and entertainers visit the home. In addition a “pat dog” visits the home, which she said is particularly enjoyed by residents. The acting manager discussed the home’s menu, which demonstrated that choice is offered to residents. However the care plans do not demonstrate that the choices and wishes of the resident in relation to diet have been identified and recorded. Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 16 &18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear updated policies, risk assessments and a knowledgeable and trained staff team protect residents. EVIDENCE: There are updated policies in place for safeguarding adults, whistle blowing and risk management, which staff stated they followed. A copy of the complaints procedure is displayed in each bedroom, and is contained in the service user guide. Staff said that they have received training in regard to safeguarding adults. They therefore have the knowledge to protect residents from possible abuse. Records show that there have been no formal complaints or safeguarding adult referrals since the last inspection. Residents said that they know how to make a complaint, and that when they talk to staff they always help to put things right Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is maintained, is clean and tidy providing a comfortable home for residents. The infection control policy of the home is not being followed which places residents at risk. EVIDENCE: Improvements have been made to the environment of the care home since the last inspection. A number of rooms have been decorated and personalised. Bedrooms look very individual containing personal possessions of residents. The standard of cleaning has improved. All areas of the home were found to be clean. The proprietor stated that ongoing maintenance continues to be carried on to improve the general environment of the care home. Residents said that they were very satisfied with the home. Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 Page 15 There was an issue raised regarding the heating of the residents lounge area which is split into two sections by dividing doors. Attention is needed to the heating system in one of the areas, as the normal radiator does not work. Alternative heating has been provided. Residents stated their satisfaction with their individual rooms and the general cleanliness of the home. One resident stated, “the home is very nice”. At the last key inspection it was identified that clinical waste was not being disposed of in a safe manner. On the day of this site visit action had still not been taken to address this matter. Clinical waste was still being disposed of through normal waste containers. This practice does not follow the infection control policy of the care home. The proprietor was requested to address this matter urgently and to find a contractor who will provide appropriate containers and arrange for the removal of clinical waste. The acting manager informed the Commission on October 2nd 2007 that a contract had been set up for the disposal of clinical waste. She stated that the infection control policy of the care home is now being followed. Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 27,28,29 & 30 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents are supported by well-trained staff, who have been recruited safely using the up-to-date recruitment policy of the care home. EVIDENCE: Residents stated that they felt there was sufficient staff on duty to meet their needs. On the day of the site visit only six residents were living at the home. Staffing levels are set for an occupancy of 14. Staff stated they could safely meet the needs of residents with the numbers of staff allocated to each shift. The inspection of the recruitment records for a new member of staff confirmed that the care homes recruitment policy is being followed. There was a copy of the interview notes, application form, two written references and the current criminal record bureau check on the staff member’s file. The acting manager stated that these checks had been completed prior to employment being offered. Recorded dates on records confirmed this statement to be correct. There was evidence of inductions being provided to new members of staff. Discussions with staff, the inspection of training records and statements made by the acting manager confirmed that an updated training plan is in place. Training records demonstrated that both core training and specialised training, Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 Page 17 including dementia awareness, was being provided. A number of staff are presently taking NVQ training. Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Procedures are in place to ensure that resident’s finances are protected. Care Plans and care assessments can be improved they lack detail which could result in unmet need. Formal supervision is not been provided to all staff this will directly affect staff development and the monitoring of care practice. EVIDENCE: There is an acting manager in post who provides positive support to all staff. An application for her to become the registered manager has not yet been made to the Commission for Social Care Inspection. Staff spoken to stated that they feel supported by the acting manager. They stated teamwork has improved considerably since the last inspection. Records demonstrated that there are procedures in place to protect the finances of residents. Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 Page 19 At the last key inspection no staff received formal supervision. On the day of this site visit all staff had received appropriate formal supervision except one member of staff on night duty. The proprietor and acting manager stated they would ensure this standard is met in the future. Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 Page 20 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 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 8 9 10 11 3 X X X X X X 1 2 3 3 3 X STAFFING Standard No Score 27 3 28 3 29 3 30 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 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 X 3 Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 Page 21 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 OP7 Regulation 15 Requirement Care plans must demonstrate that all the needs of the resident have been identified. This includes social needs and care needs, as well as resident’s preferences. This is to ensure all needs are identified, before a decision is made whether their needs can be met by the resources of the home 2 OP26 13 (1) 3 Staff must follow the infection control policy of the care home. This was a requirement at the l key inspection held on 11/04/06 And the key inspection 05/04/07 This is to ensure residents are not placed at risk of infection 04/10/07 Timescale for action 25/11/07 Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 Page 22 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 OP36 Good Practice Recommendations Care staff should be supervised according to national guidelines. This is to insure that staff development and care practice is being monitored. Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Noss Mayo Residential Home DS0000044376.V351575.R01.S.doc Version 5.2 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. 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