CARE HOMES FOR OLDER PEOPLE
Radcliffe Manor House Care Home 52 Main Road Radcliffe On Trent Nottingham NG12 2AA Lead Inspector
Lee West Unannounced Inspection 18th November 2005 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Radcliffe Manor House Care Home Address 52 Main Road Radcliffe On Trent Nottingham NG12 2AA 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) 0115 911 0138 The Trustees of Radcliffe Manor House Mrs Valerie Dixon Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 2nd November 2004 Brief Description of the Service: Radcliffe Manor House Care Home is a charming care home owned by the Trustees of Radcliffe Manor House, a voluntary organisation and registered charity. It is located in the village of Radcliffe on Trent, on the main road into the village, a short walk to the village centre has shops, library, health care services, places of worship and other amenities within reach. The building, which has operated as a care home since 1957, is a converted and extended manor house, providing personal care and accommodation for24 older people. All bedrooms are single, five having en-suite facilities. There is a passenger lift to the first floor. The gardens, which are accessible and have seating, are well maintained and surround the home. Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection commenced at 11.30am. The method used was Case Tracking where 4 Service users were spoken with about their experiences and expectations of living at the home, analysis of the records and talking with 4 members of staff to ensure that those living at the home have their needs met and their health and welfare maintained appropriately. Visitors were also spoken with for their views. The Deputy Manager, Jackie Keir, assisted during the inspection and a tour of the premises was also undertaken. The activities organiser was busy with a large number of the service users in the lounge area and the laughter and chatter made it evident the activity was enjoyed by all. Mr. Ross, the accountant for the home, was also present and his dog was being fussed by some of the ladies in the lounge. Radcliffe Manor provides care for 24 service users, is well maintained with pleasant gardens. The décor and furnishings reflect the homely atmosphere within the home and the individual rooms are as the service users want them. The home has a vertical lift and the corridors have grab rails. The home is clean and fresh smelling. The food served at lunchtime appeared appetising and was served in pleasant surroundings. What the service does well:
The service users spoken with are all satisfied with the care they receive and with the home’s pleasant surroundings. The activities organiser was working with a large number of the service users at the time of the inspection and the dog belonging to the accountant was a welcome visitor for the service users. One commented how much they enjoyed having the dog there as they had a dog before coming into the home. The service users spoken with said they were satisfied with the activities, which was reflected in the high number taking part. The visitors spoken with also all spoke highly of the activities and the general cheery atmosphere within the home. The visitors all said they are made welcome and offered drinks. Meals are served in a pleasantly decorated dining room with small groups around circular tables. The food is appetising and there is choice available. The sweet trolley contained a variety of choices, seen during the inspection. The staff were observed during the inspection treating the service users with dignity and respect when addressing them and when entering their rooms. Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 Page 6 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
Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 Page 7 contacting your local CSCI office. Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 Page 8 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 Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 Page 9 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): 1,3,5, The service users have information to make a decision about the home, they have the opportunity to visit and stay to assess its suitability, and have their needs assessed before they move into the home. EVIDENCE: The service user guide gives clear information about the home, its facilities and before coming into the home the Manager and Deputy visit the prospective service user and prepare an assessment of needs. A copy of an assessment was seen in the files case tracked, which included risk assessment. Potential service users are encouraged to visit and at the time of inspection a service user was staying to judge whether this home is suitable. At present no service users are for intermediate care. Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11, The service user’s needs are set out individual care plans but do not identify how these needs are to be met. Procedures are in place for dealing with medicines, but the method of dispensing is not appropriate. The service users are treated with respect and their wishes at time of their death are addressed. EVIDENCE: Individual care plans were case tracked and each set out the needs of the service user. The plans though did not show how these needs are to be met, what actions the carers need to take to address the needs. The plans seen did identify individual wishes upon death. During the inspection all interactions between staff and service users were seen to be respectful and privacy was encouraged also by the staff. The medication was given out during the inspection. This was from a tray trolley in the kitchen although for security it was not appropriate and a lockable mobile medicines trolley would be much more suitable. The home had been visited by staff from Boots who also said the same thing. All the medicines were given appropriately and all the Medicines Administration Records were seen to be accurately recorded. All medicines seen were within
Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 Page 11 date and correctly stored within locked cupboards when not being dispensed from the tray. Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, The home provides excellent organised activities in and around the home. Family and friends are encouraged to visit and made welcome. The service users here are helped to exercise choice and remain in control over their lives. The food appears wholesome, balanced and is served in a pleasant dining room. EVIDENCE: During the inspection, the activities organiser was busy in the lounge area with a large number of the service users. The inspector observed this and all the service users involved were laughing and joining in. There was a dog on the premises and this was adding to the delight of some of the service users who were fussing him. The activities include trips out and a recent one to Wheatcrofts, according to service users spoken with, was very pleasant and enjoyable. Service users spoken with also said how much they enjoy the activities, “especially as they usually start with bingo”. Others said that they “loved the dog being around its just like being at home”. The organiser keeps records of who attends activities and there was evidence shown to the inspector of how she tries to include “special individual needs”. Visitors spoken with also said how much everyone enjoys the activities. Service users were observed going in and out of the home when they wished. Some were dressed for the cold and walking around the grounds, others went
Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 Page 13 into the local vicinity. Service users said they feel independent and can go where they wish, so long as staff know where they are. Visitors spoken with said they are always made to feel welcome at the home and are offered drinks if required. The lunch was served during the inspection and the service users all said how satisfied they are with the food, which was fish and chips. There was a selection of desserts to choose from and everyone was given a choice. The dining room was pleasantly set out with small groups around each table. Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16.17.18 Complaints are taken seriously and dealt with and the service users are registered to vote and privacy of their personal mail is maintained. The service users are protected from abuse. EVIDENCE: Service users, visitors and staff all confirmed that they are aware of the complaints procedures and would not feel uncomfortable in complaining if it was necessary. The complaints procedure is followed and this was evidenced by the complaints book. There are regular “Residents Meetings” and the minutes of these were seen; some clearly show complaints discussed and dealt with. All of the service users are registered to vote and this was confirmed by those spoken with. They also receive all their personal mail, unopened. The staff spoken with today are aware of the procedures around the Protection of Vulnerable Adults from abuse, they would report any issues to person in charge, however, they have not received formal training in this area. No evidence was seen within the staff files of any formal training in this area. Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 Page 15 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): 19,20,21,22,23,24,25,26 The Home is well maintained, accessible with well-used indoor and outdoor communal facilities. The entrance to the home is unlocked, leading to possible risks to service users and the outside rear of the home is quite dark. There is a new build of some blocks of flats in close proximity to the back to the home. The home is comfortable, clean and pleasant and the service users’ rooms suit their needs with their possessions around them. There are sufficient toilet and washing facilities and specialist equipment is available if required. EVIDENCE: The home is pleasantly decorated and furnished with the rooms reflecting the personalities of the service users. Those spoken with were happy with their rooms and said they were “very comfortable”. On entering the home the inspector could not find any staff and wandered around the home for fifteen minutes before finding someone to ask where the staff were; the staff were having a meeting. There is an alarm on the door to let people know it is opening, but this is constantly ringing and staff, who may be busy elsewhere, do not check who is coming in or out. A lock to allow service users free access
Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 Page 16 and restrict incoming visitors is necessary to protect the vulnerable service users. The service users have their own possessions around them in their rooms and there are sufficient toilet and washing facilities within the home. The communal facilities are clean and hygienic. During a tour of the premises it was noted that there is a new building development very close to the boundary of the home and the rear gardens would benefit from some security lighting to give added protection to the service users. Specialist walking equipment was seen to be used during the inspection and this was kept well maintained. l Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 Page 17 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): 27,28,29,30 The staff numbers and mix met the needs of the service users and they are competent to do their jobs. Staff recruited all have current Criminal Records Bureau checks, but not every staff file had two references in place. EVIDENCE: The number of staff on duty during the inspection were observed to be meeting the needs of the service users. The service users said they were satisfied with the staff numbers, “they are always there when they are needed.” Staff spoken with are aware of their role within the Protection of Vulnerable Adults, but they said they had not received formal training within this. Some staff spoken with did not have first aid training or any training in dementia care. Two staff members did have National Vocational Training Certificates at Level 2. All staff records seen during the inspection showed training for moving and handling had been carried out. Staff records inspected contained Criminal Records Bureau checks, however, not all files had two references and some terms and conditions of employment were not signed or dated. Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38 The home is well run and supported by the Board who endeavour to ensure that all is done for the benefit and in the best interest of the service users. A Registered charity, the finances are dealt with by Mr. Ross – treasurer – and the appropriate financial procedures adhered to. The staff have regular supervision and the Manager and Board of Trustees address the health, safety and welfare of service users and ensure records, policies and procedures are followed. EVIDENCE: Card information system giving instant access to details and telephone numbers for each service user is used and kept in the office. This assists anyone who needs to contact someone in an emergency to gain immediate access to non-confidential information. The Manager and deputy maintain the records of the home, health and safety checks are regularly carried out, as seen in the recording documents. Fire alarm testing, legionnella and routine
Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 Page 19 maintenance records were all observed during the inspection and staff and service users also confirmed that regular fire alarm testing takes place. The accident/incident recording documents do not at present meet the current data protection requirements. The home is run in the best interest of the service users and the minutes of the residents’ meetings are an indication this is the case. Service users spoken with also said that they felt that they were valued and that things were “done to help me feel at home.” Staff files showed that supervision was being carried out, but this is not up to date or regular. Staff said that they do have supervision and also discussions about their work. The financial records are kept by Mr Ross, who maintains them in order. All money is kept safely locked away. All records are kept securely locked away. All the required insurances are up to date and at the appropriate level of cover as indicated by the Certificates displayed within the home. Notifications of death or significant incidents are now being reported regularly to the Commission and the providers are also carrying out regular inspections of the establishment as evidenced by copies seen by the inspector. Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 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 3 X 3 X 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 3 3 Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? None 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(1) Requirement Ensure preparation of a written plan as to how the service user’s needs in respect of health and welfare are to be met Ensure safe keeping and safe administration of medicines received into the home by providing a lockable trolley for the distribution of medicines within all areas of the home Ensure unnecessary risks to health or safety of service users are identified and so far as possible eliminated by providing a lock on the front door to prevent entry of all except service users and staff. Reduce unnecessary risks to safety of service users so far as possible by installing security lighting in the garden areas around the home Ensure that two satisfactory written references are obtained before appointing a member of staff Timescale for action 01/02/06 2 OP9 13(2) 01/02/06 3 OP19 13(4)(a) 25/11/05 4 OP19 13(4) (c) 06/01/06 5 OP29 19(4) 25/11/05 Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 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 Ensure that care staff receive formal supervision at least 6 times a year. Radcliffe Manor House Care Home DS0000008736.V272020.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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