Inspection on 02/08/05 for Notrees

This inspection was carried out on 2nd August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Notrees 18/04/07

Notrees 07/02/06

Notrees 11/01/05

Notrees 19/08/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE NOTREES 10 High Street Kintbury Berks RG17 9TW Lead Inspector Tracy McGuire-Brown Unannounced 2 August 2005 9.00am 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. NOTREES H51-H01-S31304-Notrees-V242297-020805-Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Notrees Address 10 High Street, Kintbury, Berks, RG17 9TW 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) 01488 658332 West Berkshire District Council Ms Susan Mary Goalby Care Home (CRH) 18 Category(ies) of Old age, not falling within any other category registration, with number (OP) 16 of places Learning disability (LD) 2 NOTREES H51-H01-S31304-Notrees-V242297-020805-Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: One service user is currently under 65 - no further service users under 65 to be admitted. Date of last inspection 11 January 2005 Brief Description of the Service: Notrees provides 24-hour residential accommodation and care for up to 16 elderly people.West Berkshire Social Services are the authority responsible for the overall management of the home.The home is situated in the village of Kintbury and has excellent community links.The home is a single storey building situated back from the road with a large parking area to front of the building and well maintained grounds surrounding the property.The home has a large conservatory at the front and a large sitting/ dining room. There is a large kitchen and a smaller kitchen area used to make coffee etc. Service Users rooms are located off two corridors which are accessed via the lounge /dining area.The home benefits from having a small private lounge, which can also be used for relatives/carers to stay overnight. Most Service Users rooms have individual en –suite facilities NOTREES H51-H01-S31304-Notrees-V242297-020805-Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection carried out over a 7-hour period. The Inspector looked at the building, spoke to the Manager and members of staff on duty. Resident files and care plans were seen, as were other records. The Inspector also had the opportunity to speak to a visiting friend of a resident and the Boots Pharmacy advisor. The Inspector spent some time talking to a number of residents in the home. What the service does well: What has improved since the last inspection? What they could do better: NOTREES H51-H01-S31304-Notrees-V242297-020805-Stage 4.doc Version 1.40 Page 6 There were some medication errors, which require some attention. There could be more activities offered but this would require some additional staffing to achieve. 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. NOTREES H51-H01-S31304-Notrees-V242297-020805-Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection NOTREES H51-H01-S31304-Notrees-V242297-020805-Stage 4.doc Version 1.40 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 standard(s) 3 All Service Users have a full assessment completed prior to admission. EVIDENCE: Individual records are kept for each Service User. A sample of records for the most recent admissions was seen; each file contained a full and detailed care management assessment, which was completed prior to admission. Additional “trial visits” and “meeting with potential Service User” documentation is completed if possible. Additional information from other professionals’ e.g. Occupational therapists is sought if required. NOTREES H51-H01-S31304-Notrees-V242297-020805-Stage 4.doc Version 1.40 Page 9 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) 7,8,9,and 10 Service Users all have an individual care plan detailing health, personal and social care needs. Service Users health needs are met. Medication procedures in the home are generally good but there have been some recent errors.. Service Users are treated with respect and their privacy is respected at all times. EVIDENCE: Service User plans are completed for each individual. The current plans are basic and limited in detail. The Manager informed the Inspector that the care plans are being reviewed and a new format being designed, a sample of the new format was shown to the Inspector, this document was more detailed. The new format is currently in the consultation process but is due to be implemented in the near future. Samples of care plans seen by the Inspector identify health personal and social needs. Care plans are reviewed on a regular basis and there is documentation in place to evidence when reviews have been completed. Each Service User has individual healthcare records; these have been improved and now clearly detail all healthcare appointments undertaken. There are also healthcare treatment sheets which detail treatment from e.g. District Nurse, G.P. and Chiropodist. NOTREES H51-H01-S31304-Notrees-V242297-020805-Stage 4.doc Version 1.40 Page 10 The home has detailed medication policies and procedures in place. Staff who administer medication have all received training and samples of these certificates were seen on staff profiles. On the day of Inspection the Boots pharmacist was visiting to undertake a routine quarterly check on the medication in the home. The Inspector was present throughout the feedback and had some discussion with the Pharmacist. The Pharmacist found some errors in the medication recording sheets. Feedback was also given in respect of some storage issues. Staff in the home and Manager were immediate in undertaking action plans to address the issues raised. Medication procedures must be robust at all times. This will be a requirement of this inspection. The Inspector observed staff working a professionals and sensitive manner at all times with all Service Users. Staff always knock on Service Users door and address Service Users in a professional manner Service User spoken to feel they have privacy. NOTREES H51-H01-S31304-Notrees-V242297-020805-Stage 4.doc Version 1.40 Page 11 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) 12,13,14 and 15. Service Users social, cultural and recreational needs are met. Service Users choice to maintain contact with family, friends and relatives is met. Service User are encouraged and supported to exercise choice and control over their lives. Service Users have a well balanced diet with choice always available. EVIDENCE: The home has recently conducted a survey of all Service Users request in respect of recreational activities, these surveys are n the process of being collated and typed up. The samples of surveys seen include requests to play golf, go to the pub and have outings. Staff in the home work hard to put on varied group and individual activities on a daily basis. There is an activities file and each activity and who participated is recorded. The manager informed the Inspector that each Service User is encouraged to participate in an activity through the week. On the day of inspection a game of Bingo proved to be a popular activity. There is no dedicated Activity co-ordinator post in the home and so care staff assume this role. The home would benefit from more staff or and activity coordinator to create more activities throughout the day. Some Service Users attend external day services. On the day of inspection one Service User had a visitor who spoke positively about the home and how visitors are made to feel welcome. Service User daily records and care plans detail contact with family friends and relatives. Service Users spoken to informed the Inspector they have regular visitors. NOTREES H51-H01-S31304-Notrees-V242297-020805-Stage 4.doc Version 1.40 Page 12 Service Users in the home informed the Inspector that they are able to bring their own possessions in to the home. Service Users are supported to exercise choice and control over their finances dependent on capacity. Service Users in the home were very positive about the choice and taste of meals provided in the home. A detailed menu is on display in the dining area. Time was spent talking to the cook who showed the Inspector a range of records including the four-week menu plan, which is compiled after consultation of Service Users, likes and dislikes. All foods consumed are recorded on a daily basis and samples of food kept as required. The cook is able to cater for a range of needs, which currently include a diabetic and soft diet. Drinks and snacks are available throughout the day. Service Users can choose to eat in the dining room or their own room if they choose. Service Users were observed at breakfast and lunchtime and the food was well presented and enjoyed by the Service Users. Staff were available and offered support and assistance in a sensitive manner if required. NOTREES H51-H01-S31304-Notrees-V242297-020805-Stage 4.doc Version 1.40 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 standard(s) 16 and 18 The home deals appropriately with complaints and protects Service Users from abuse. EVIDENCE: The home has detailed complaints procedure available at all times in addition there are posters on display detailing who to and how to complain. A log is maintained of all complaints. The log details how complaints are responded to and this action is satisfactory. There have been no complaints since the previous inspection. Staff and Service Users spoken to were all clear about how they could complain if they needed to. The home adheres to the local inter agency vulnerable adults procedures. Staff receive training in the protection of Vulnerable Adults and the Inspector saw certificates of this training. NOTREES H51-H01-S31304-Notrees-V242297-020805-Stage 4.doc Version 1.40 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 standard(s) 19 and 26 The home is safe and comfortable with appropriate facilities available. The home is well maintained with high standards of cleanliness throughout. EVIDENCE: The home is well presented and there is a variety of communal space including a large lounge/dining room some smaller lounges, a sensory room and large garden. The home is furnished to a good standard. The home was clean and tidy throughout and the domestic was cleaning some carpets on the day of inspection. The home has a detailed infection control polity in place. NOTREES H51-H01-S31304-Notrees-V242297-020805-Stage 4.doc Version 1.40 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 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) 27,29,and 30 Staff in the home are experienced and well qualified. The home has robust recruitment procedures. Staff are well trained. EVIDENCE: The home is currently fully staffed although some shifts are covered by agency staff due to a long-term sickness and annual leave cover. On the day of inspection the staff cover was satisfactory. Agency staff seen on the day of inspection were professional and had a good rapport with the permanent staff and Service Users. The home would benefit from some extra staff to cover activity provision in the home. Each member of staff has a detailed profile in place which details training undertaken and training due, copies of certificates gained from training are kept in this file and demonstrate that the staff are well qualified with varied skills. Staff in the home are qualified to NVQ level 2 or above (one member of night staff is currently undertaking level2). The Manager also has a detailed training plan on the wall in the office identifying training needs and updates required. Recruitment in the home is robust. Recruitment processes are dealt with in a clear process by the local authority personnel department with the home Manager being involved at all times. Recruitment records and checks are all completed prior to employment. Records were seen of interviews and references are always undertaken. All recruitment records required were available on the sample staff records viewed by the Inspector. NOTREES H51-H01-S31304-Notrees-V242297-020805-Stage 4.doc Version 1.40 Page 16 NOTREES H51-H01-S31304-Notrees-V242297-020805-Stage 4.doc Version 1.40 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 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) 35 and 38 Service Users financial interests are safeguarded. Service Users health, safety and welfare are also safeguarded. EVIDENCE: Service Users money is kept separately and individually in a locked cabinet, only 3 staff members have access to this. Service users have money in bank accounts; relatives or solicitors manage some service users finances. All cash held is recorded and every transaction accounted for and signed by at least 2 people, where possible Service Users sign for their money. Sample accounts were seen and were well documented with receipts available. A random sample was checked and balanced correctly. Health and Safety maintenance checks are completed regularly and records are kept. Health and safety is covered in all staff inductions. NOTREES H51-H01-S31304-Notrees-V242297-020805-Stage 4.doc Version 1.40 Page 18 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 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x 3 x x 3 NOTREES H51-H01-S31304-Notrees-V242297-020805-Stage 4.doc Version 1.40 Page 19 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 9 Regulation 13 (2) Requirement Medication procedures must be robust at all times Timescale for action 31/08/05 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 12 Good Practice Recommendations Consider the need for additonal staff to provide more activities for Service Users. NOTREES H51-H01-S31304-Notrees-V242297-020805-Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection 2nd Floor, 1015 Arlington Business Park Theale Berks RG7 4SA 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 NOTREES H51-H01-S31304-Notrees-V242297-020805-Stage 4.doc Version 1.40 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. 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