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Inspection on 27/06/05 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 27th June 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 good quality care taking into account the choices and wishes of individual service users. The staff team work well together and feel supported by the registered manager. Service users receiving long-term care are provided with security and a good quality of life.

What has improved since the last inspection?

All new service users receive a full assessment before being admitted to the care home, this was not the case at the last inspection. The care plan records are now filed in a consistent manner.

What the care home could do better:

Despite the last inspection report stating the Commission was considering enforcement action due to the proprietors failure to carry out essential maintenance, no progress has been made. This maintenance, which has been outstanding since 22 January 2003. The present owners have owned the home since May 2003. The condition of the window frames in particular is unacceptable. The proprietor has failed to fit radiator covers as agreed in his action plan for the last inspection. Staff are not being provided with supervision and appraisals. The health and safety issues which were identified at the past inspections have still not been addressed by the proprietor. Specialised training for staff is not being provided. Individual service users rooms have not been provided with the equipment as set out in the national minimum standards.

CARE HOMES FOR OLDER PEOPLE Noss Mayo Residential Home 2 High Street Burgh le Marsh Skegness Lincs PE24 5DY Lead Inspector Ken Hague Unannounced 27 June 2005 @ 8am 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 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 C53 C04 S44376 Noss Mayo V234839 27-6-05 Stage 4.doc Version 1.30 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 Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr P C Kadccha Mrs Jennifer Easom Care Home Only (CRH-PC) 14 Category(ies) of DE(E) - Dementia Over 65 years - 1 registration, with number OP - Old Age - 13 of places Noss Mayo Residential Home C53 C04 S44376 Noss Mayo V234839 27-6-05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The registration for 1 DE(E) placement is on a named basis only. Date of last inspection 22 September 2004 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 C53 C04 S44376 Noss Mayo V234839 27-6-05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a six hour period. A detailed tour of the premises was conducted and care records were inspected. The registered manager and one member of staff was interviewed. Five service users and one relative was interviewed. 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 C53 C04 S44376 Noss Mayo V234839 27-6-05 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Noss Mayo Residential Home C53 C04 S44376 Noss Mayo V234839 27-6-05 Stage 4.doc Version 1.30 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 standard(s) 2,3 & 5 The admission process enables service users to make an informed choice about coming to live at the care home. The assessment makes information about them available to all staff. EVIDENCE: The home has a statement of purpose which sets out the resources offered by the care home. This document was seen on the inspection and was displayed in the reception area. The registered manager stated that all service users are invited to visit the home before making any decision. The service user interviewed who had been admitted recently to do home confirmed this to be the case. Care files provided evidence that all service users are given an initial assessment before being admitted to the home. The assessment included the choices and wishes of service users. All the files contain a copy of the terms and conditions for the service users stay at the home and these were signed and dated. Noss Mayo Residential Home C53 C04 S44376 Noss Mayo V234839 27-6-05 Stage 4.doc Version 1.30 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 standard(s) 7,8 &10 Service users health care needs are recorded with plans of how these should be met. This enables staff working closely with community services and the hospital to ensure any identified needs are met. The privacy and dignity of service users is respected. EVIDENCE: Service users stated to the Inspector that staff were careful and sensitive in the manner in which they provided care. The Inspector observed staff to knock before entering rooms while he was conducting the inspection. In her formal interview a member of staff stated while providing care “it is important that we always remember to respect the dignity of the residents we are helping.” The health, personal and social care needs were identified and recorded in the sample of care plans seen during this visit. All files contained nine basic care plans which address areas of potential care needs. The service users files inspected all have these nine care plans assessed and where a need was identified it was recorded including how this need was going to be met. The care plans were signed by the service user or a member of the family. Noss Mayo Residential Home C53 C04 S44376 Noss Mayo V234839 27-6-05 Stage 4.doc Version 1.30 Page 9 The pen picture which included a medical history was found to be included in every file. There was evidence of eye care, chiropody and dental care being provided. The files contained details of visits by doctors and district nurses. Noss Mayo Residential Home C53 C04 S44376 Noss Mayo V234839 27-6-05 Stage 4.doc Version 1.30 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 standard(s) 12,13&15 Relatives and friends of service users are made welcome to the home. Meals are well managed and reflect the likes and dislikes of service users. A range of activities is provided to service users. EVIDENCE: A number of service users were spoken to at breakfast time and commented “the food was very good.” The service users confirmed that they were consulted each evening regarding the menu for the following day. The menu offers choice and the likes and dislikes of service users were recorded on their individual files. This care plan also records if service users require help with eating their meals. A care plan stated “this service user prefers to have breakfast on a tray in his bedroom.” The care files contained the choices of activities for individual service users. One referral stated “likes playing dominoes”, “enjoys family visits”. A second care plan states “this service user likes to read books, wants to join in group activities, is interested in gardening enjoys both games and musical entertainment”. Visitors also came to the home during an inspection. One visitor stated that he visits frequently throughout the week and is always made welcome by staff. Noss Mayo Residential Home C53 C04 S44376 Noss Mayo V234839 27-6-05 Stage 4.doc Version 1.30 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 standard(s) 16,&18 The home has a complaints policy which is known to staff and service users. Service users are able to raise any complaints of concerns using this procedure or through service user meetings. EVIDENCE: The complaints procedure meets the national minimum standards. Service users who were interviewed confirmed that they were confident and felt able to raise any concerns with staff or the registered manager. The home has within its procedure manual a vulnerable abuse procedure and a copy of the Lincolnshire County Council Vulnerable Abuse Policy. Staff were able to discuss the abuse procedure. Noss Mayo Residential Home C53 C04 S44376 Noss Mayo V234839 27-6-05 Stage 4.doc Version 1.30 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 standard(s) 19,20,21,23,24,25&26 The proprietor has not carried out the necessary maintenance since the last inspection. There are serious concerns relating to the urgent repair or replacement of windows and guttering. Some windows cannot be opened in summer or closed appropriately in winter. Requirements identified at the last inspection have not been actioned. Service users comfort, health and welfare is at risk. EVIDENCE: It was identified in January 2003 that urgent repair or replacement of the windows was necessary. In May 2004 the Commission was told that work was to be carried out, but this has not happened. At this inspection some windows could not be opened. There were windows propped open with a piece of wood or stone. A window was wedged open with a piece of the wood to stop it rattling. There were numerous cracked panes. Many windows were sealed with tape to stop draughts. There were windows where large amounts of putty holding the pane in had fallen off. Window sills were rotten and need urgent replacement. Noss Mayo Residential Home C53 C04 S44376 Noss Mayo V234839 27-6-05 Stage 4.doc Version 1.30 Page 13 The cast iron guttering was broken in places and guttering was full of soil and grass. The gable end of the building had two areas which need evaluation as there are large cracks in the brickwork and it looks to be bulging. A radiator cover required from the last inspection has not been fitted. The comfort of service users will be directly affected in the winter if these repairs are not completed. The condition of glass panes presents a health and safety issue to staff and residents. The jamming of windows with wooden wedges and pieces of stone presents a health and safety hazard. There is evidence of damp in the ceiling in a bedroom. The proprietor was advised by telephone of the serious concerns identified relating to the environment. The proprietor was told an urgent action plan was required which should include start dates for the urgent work to ensure that the home meets the Care Home Regulations in respect of the environment. He was reminded of the time delay in carrying out this work and the failure to meet the requirements on previous inspections. The proprietor stated that as the building is listed obtaining appropriate windows and planning permission is proving difficult. An immediate requirement notice was left with a care home. A bedroom seen during a tour of the home contained no lockable storage facility. Noss Mayo Residential Home C53 C04 S44376 Noss Mayo V234839 27-6-05 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29,30 The home failed to followed its recruitment policy and regulatory requirements in respect of the last member staff recruited at the home. Service users could therefore have been placed at risk. The home is not providing staff training in a consistent planned manner and this could affect the standard of care the residents receive. EVIDENCE: A member of staff who recently commenced employment does not have a current criminal records bureau disclosure (CRB) but does have a protection of vulnerable adults list (POVA) check. The registered manager and another member of staff confirmed that this person was providing personal care unsupervised. A member of staff who started her employment with a POVA check, but no CRB is not allowed to work unsupervised at any time within the care home. The register manager confirmed that there is no written training plan for staff identifying training to be provided over the next year. No specialised training courses have been offered to staff. Noss Mayo Residential Home C53 C04 S44376 Noss Mayo V234839 27-6-05 Stage 4.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,36&38 The registered manager is supportive to all care staff, but they are not being provided with supervision or appraisals and there is no quality assurance process. The home cannot judge whether the service users are satisfied with the service it provides and staff development is not taking place. The proprietor and registered manager have a legal responsibility to ensure the home meets the Care Home Regulations. They have failed to take action to address identified requirements from the last three inspections. EVIDENCE: The staff interviewed during this inspection stated that their registered manager was helpful and supportive to all staff. The registered manager stated that supervision or appraisails have not been provided in accordance with the National Minimum Standards. The staff confirm this to be the case in formal interviews. She also stated that there was no quality assurance monitoring system in place. The failure to address requirements identified in relation to health and safety such as windows and radiator surfaces could lead to service users being placed at risk. Noss Mayo Residential Home C53 C04 S44376 Noss Mayo V234839 27-6-05 Stage 4.doc Version 1.30 Page 16 There were 11 requirements on the last inspection report, only two were found to be met at this inspection. Six of the 11 requirements were outstanding from previous inspection reports. Noss Mayo Residential Home C53 C04 S44376 Noss Mayo V234839 27-6-05 Stage 4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 1 3 3 x 3 2 1 3 STAFFING Standard No Score 27 x 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 2 x x 2 x 1 Noss Mayo Residential Home C53 C04 S44376 Noss Mayo V234839 27-6-05 Stage 4.doc Version 1.30 Page 18 no Are there any outstanding requirements from the last inspection? 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 25 Regulation 13-4 Requirement Timescale for action August 31 2. 3. 4. 36 33 19 5. 24 6. 30 The registered person must ensure that unnecessary risk to the health or safety of service users are identified and as far as possible eliminated, particularly relating to the temperature of hot water and radiators. 18-2 The registered person must provide induction, supervision and appraisals for all staff. 24 The home must have in place a quality assurance monitoring system 23 (2) 9b) All windows and frames in the home must be maintained, repaired or replaced where necessary. Outstanding from previous inspections 22/01/03 12/05/04 and 8/02/05 16 (2) (b) Service users must be provided with lockable storage space in their bedrooms. Identified previously at the inspection on 12/5/04 18 (1) The registerd manager must ensure that the content of training courses are appropriate to meet the needs and that they are run by accredited trainers identified at previous inspection on 26/07/04 C53 C04 S44376 Noss Mayo V234839 27-6-05 Stage 4.doc August 31 August 31 September 30th September 30th September 1st Noss Mayo Residential Home Version 1.30 Page 19 7. 36 18-2 8. 28 !8-1 C 9. 30 30-4 c Supervision arrangements must be put in place for all staff identified at previous inspection on 26/07/04 The registered person must ensure that persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform - including time for the purpose of obtaining further qualifications appropriate to such work from inspection report 27/07/04 The registered person must ensure that unnecessary risk to the health and safety of service users are identified and insofar as possible eliminated. From the inspection report 26/07/04 September 1st 30th November 05 September 1st 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 none Good Practice Recommendations Noss Mayo Residential Home C53 C04 S44376 Noss Mayo V234839 27-6-05 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 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 C53 C04 S44376 Noss Mayo V234839 27-6-05 Stage 4.doc Version 1.30 Page 21 - 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!