Inspection on 14/08/07 for Stephenson Court Nursing Home

This inspection was carried out on 14th August 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.

Other inspections for this house

Stephenson Court Nursing Home 29/07/09

Stephenson Court Nursing Home 04/02/09

Stephenson Court Nursing Home 22/07/08

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Stephenson Court Nursing Home Station Road Forest Hall Newcastle Upon Tyne NE12 9BQ Lead Inspector Alan L Baxter Key Unannounced Inspection 09:45 14 & 15th August 2007 th 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 Stephenson Court Nursing Home DS0000069661.V342325.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. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stephenson Court Nursing Home Address Station Road Forest Hall Newcastle Upon Tyne NE12 9BQ 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) 0191 2702000 Southern Cross Healthcare (Focus) Limited Mrs Christine Cass Care Home with nursing. 46 Category(ies) of Old age, not falling within any other category registration, with number (45), Physical disability over 65 years of age (2) of places Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Should any of the residents in the PD category leave the home, the Commission for Social Care Inspection must be notified immediately. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places 45. Physical disability, over 65 years of age - Code PD(E), maximum number of places 1. 3. The maximum number of service users who may be accommodated is 46. 16th August 2006. Date of last inspection Brief Description of the Service: The premises are purpose built and are located within a residential area of Forest Hall. The home is close to shops and local facilities including the Metro station. The home can accommodate 46 frail elderly residents who require nursing care. Short stay respite care is also offered when rooms are available. All accommodation is within single rooms with en-suite facilities. There are two dining rooms in the home and three lounges. There is no smoking area inside the home at the moment, but adaptations that comply with new legislation are currently being considered. Car parking is situated to the front of the building and there are gardens at the back. The weekly fees range from £361:00 to £450:50. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the visit: We looked at: • Information we have received since the last visit on 16th August 2006. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on the 14th and 15th August 2007. During the visit we: • • • • • • Talked with people who use the service, relatives, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building/parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager what we found. This is the first inspection of the home under its current ownership. What the service does well: The home makes sure that it can meet the needs of new residents by carrying out good assessments before they come into the home. Detailed care plans are drawn up to meet the needs identified in those assessments. This means that the residents and staff both know how the care is to be given. The health care needs of the residents are closely monitored and met. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 6 Medicines are carefully stored and administered. Staff protect the privacy and dignity of residents. The home keeps good links with the local community and encourages relatives and friends to visit the home. Residents are encouraged to choose how they spend their days and to be as independent as possible. Residents are very well groomed. There is a good, varied and nutritious menu, with plenty of choice. Residents say that they enjoy the food. Complaints are taken very seriously by the manager and are quickly sorted out. All staff have been trained to protect residents from abuse. Residents’ money is kept safe for them, where requested. The home provides a clean, safe, comfortable and pleasant environment for its residents. The home is well staffed, with qualified nurses as well as carers on duty at all times. Staff training is given in moving and handling, fire safety, food hygiene, infection control and first aid. The health and safety of the residents and of the staff are taken seriously, and proper systems are in place to achieve this. What has improved since the last inspection? The storage arrangements for medicines have been improved. There are better arrangements in place for getting transport to take residents out. A budget for social activities has been introduced. The home’s Adult Protection policy has been changed to be in line with local guidance. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 7 There have been some improvements in the furnishings and fixtures of the home, and more significant renewal of furniture and carpeting are planned. 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. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 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 Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No new resident moves into the home before his or her care needs have been fully assessed, and it is confirmed that the home can meet those needs. The home does not provide Intermediate Care. EVIDENCE: Assessment of Needs: The care records of three residents were examined. The company has introduced a very comprehensive range of pre- and postadmission assessments. These allow the manager to satisfy herself and the resident that all assessed needs can be met in the home. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 10 A very detailed assessment is completed before admission, to judge the suitability of the referral. Comprehensive ‘nurse to nurse’ hospital discharge letters also form part of this process. Following this, the manager completes full physical and mental health assessments, as well as detailed assessments of skin care needs, nutrition, continence and moving and handling needs. Risk assessments are also drawn up. The home does not provide Intermediate Care. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 11 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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of each resident are set out in an individual plan of care. Residents’ health care needs are assessed in detail and fully met. Residents are protected by the home’s policies and procedures for dealing with medicines. Storage of drugs has been improved. Residents confirmed that they are treated with respect by all the staff, and that their privacy is protected. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 12 EVIDENCE: Service User Plan: A separate care plan has been drawn up for each need identified in the assessment process, described in standard 3, above. The only significant exception is the lack of individual social care plans (see standard12, below). The care plans seen were of a very good standard, being detailed, specific, sensitive and well focussed. They have a welcome emphasis on maintaining the dignity of the resident, and include the need to communicate clearly with the resident, so encouraging co-operation, rather than ‘doing to’ the resident. The quality of the pre-admission assessments allows for a draft care plan to be drawn up and in place before the person has been admitted to the home. This is very good practice. The nurse in charge draws up a daily commentary on the progress of the care plans is drawn up daily. Other records, including daily charts regarding personal hygiene and other tasks, are completed by the care staff. It was a recommendation of the last inspection report that the registered person reviews the format of the daily record sheet. This recommendation has been carried out, as part of a completely new range of care documents that have since been introduced. Health Care: The manager completes thorough pre- and post-admission assessments of both physical and mental health of the residents and very good care plans are drawn up as a result of these. The company has provided a comprehensive range of recording tools, including bladder and bowel charts, fluid and nutritional intake charts, turning records etc. There is also a wide range of ‘supplementary’ recording formats available for use. These include close observation records, challenging behaviour records and pain assessment documents. There was documentary evidence of input from specialist nurses and other health professionals. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 13 Medication: It was a requirement of the last inspection report that the manager reviews the arrangements for the storage of medication. This has been carried out. Secure storage space has now been found for the drugs trolley on the ground floor. The home’s Medication Administration Records (MAR) were studied. They are well maintained. They include instructions to staff giving medicines; signatures and initials of staff, for audit purposes; and photographs of all residents, to make sure there is correct identification. Handwritten entries are signed and dated, and no gaps were seen in the MAR. A monthly internal audit of the medications is carried out (the most recent scored 98.7 ). Eye drops and creams are dated when opened, and there is a drugs fridge. Privacy and Dignity: Discussion with residents during the inspection, and feedback from questionnaires returned by residents, showed that they feel that they are treated with respect by all the staff at all times. They felt that their privacy is protected. Staff were seen to knock on doors before entering bedrooms and to treat residents with respect and consideration. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 14 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 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The does not fully explore or meet the social, religious and recreational interests of its residents. The home has reasonably good links local schools, clubs and other community facilities, and encourages and welcomes visitors. Staff help residents to make choices about their daily lives. Residents are offered a varied, appetising and nutritious diet, with plenty of choice. EVIDENCE: Social Contacts and Activities: It was a recommendation of the last inspection report that the registered person provides a budget for social activities (outstanding since 2005), and reviews the transport arrangements for the home. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 15 This has been partly carried out. A small budget for social activities has been introduced. Although the home’s own bus has not been operational for two years, the home is now using a ‘voluntary’ bus, which is bookable in advance and takes wheelchairs. Although there is a ‘personal history profile’ taken as part of the initial assessment of residents’ needs, these are fairly brief and are not always being completed. Also, there is a lack of individual social care plans. Although a ‘recreational activities record’ kept daily, this is an inappropriate, impersonal and mechanistic approach that uses codes for activities and gives no information as to quality, choice, duration, satisfaction etc. Without proper assessment, care planning and daily recording of social activities, the home cannot demonstrate that it operates an holistic approach to resident care. A requirement is made. Similarly, although there is a section in the assessment documentation regarding religion and spirituality, this is not always completed, and no evidence of spiritual care plans was seen. A requirement is made. The home has an activities co-ordinator, who works 31 hours per week in the home. She stimulates activities such as knitting circles, arts and crafts and gentle exercise. However, the recreational activities record shows that, for most residents, the commonest daily activities are watching television and chatting. The home employs visiting entertainers on a reasonably regular basis, having had two in recent weeks and another booked for August. Community Contact: Relatives and friends are given written information about the home’s policy on visiting. No restrictions are placed upon visitors, who may come at any reasonable time. Residents can choose to see their visitors in the privacy of their own bedrooms, if they so choose, and may also refuse to see a visitor if they want. The home has visits from schoolchildren from a local school at various times during the year, such as Christmas, Easter and Harvest Festival. Good links were reported. A church group visits at Christmas. The home has monthly links with the local Multiple Sclerosis club. Age Concern gives lessons to residents in the use of computers. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 16 A mobile library visits regularly. Autonomy and Choice: Care records, daily recordings, discussions with residents and observation all confirmed that residents are encouraged to make choices as to how they spend their time in the home. They have choice of when to rise and retire; what to wear; what to eat; whether to join in activities and how much time they spend in their rooms. They may bring personal possessions with them when they come into the home. Where they are willing and able to do so, they are encouraged to handle their own finances and make their own purchasing decisions. The home advertises advocacy services in the home. Residents may see their own care records when they want. Generally, the home does not seek to provide a ‘no-risk’ environment, but an environment where risks are assessed and managed, to promote as much independence as possible. Meals and Mealtimes: The company has a detailed catering policy, with clear nutritional targets against which it compares the food being offered. These targets are displayed prominently in the home. However, so long as nutritional targets are being met, there is some flexibility in the menus, which are discussed and agreed with the resident group. They were recently amended in the light of a residents’ survey. This is good practice. Menus showed that residents might have a cooked breakfast daily, if they so wish. There is choice for both the main meal of the day, lunch, and for the tea meal (a written record is kept of residents’ meal choices). Supper dishes are specified on the menus. The home’s chef is experienced and enthusiastic, with a good knowledge of the nutritional needs of the residents and their individual likes and dislikes. He was able to describe how he responds to various dietary demands such as weight-gain and weight-loss diets, diabetic diets etc. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 17 Lunch was taken with the residents. It was a pleasant experience. Dining tables were nicely set, with silk flowers in vases, proper tablecloths, salt cellars etc. The meal offered a choice of braised steak or chicken Kiev, with buttered new potatoes, carrots, peas and gravy, followed by rice pudding. The food was well cooked and presented, and very tasty, with very tender meat. Care staff were unobtrusive but attentive, and where a resident needed assistance with eating his or her meal, help was offered in appropriate ways. All the residents who spoke to the inspector said that they were happy with the food in the home. One resident was not aware that he could ask for seconds if he wished, and it was agreed that this choice would be positively offered to the residents. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 18 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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home takes any complaints or concerns very seriously, investigates them thoroughly, and reacts in a positive manner, seeking to resolve them wherever possible. Residents are protected by the policies in the home. Staff have been given training in this important area. EVIDENCE: Complaints: The complaints log has had nine entries in the past year. This is fairly average for a home of this size, and shows that manager and staff are alert to expressions of discontent as well as formal complaints. This is good practice. The entries covered a range of issues, including activities, laundry, care issues, medications, and staff issues. Each entry in the complaints log had been investigated in good detail, with documentary evidence, written statements, and evidence of remedial actions being taken (for example, the offer of compensation for damaged clothing). It Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 19 was agreed that more clarity was needed as to whether or not the complainant was satisfied with the process and/or the outcome of the complaint, and the manager has added a section to the complaints log to record this. In addition to the use of a standard complaints log, the home’s manager makes herself available in the home between 10am and midday every last Saturday of the month, specifically to see any resident, relative or visitor who wishes to discuss any complaint or other issue. This is good practice. Protection: It was a requirement of the last inspection report that the manager produces an Adult Protection policy that takes account of local procedures and guidance. This has been carried out. A simple ‘flowchart’ has been drawn up that gives the names and contact numbers of the social services officers who must be contacted and informed about any allegation of abuse that comes to the attention of any staff member in the home. It also gives ‘core’ advice, such as making residents safe and telephoning the police, where appropriate. This is good practice, as it will speed up the home’s response to such allegations. The home has had one allegation of alleged physical abuse by a staff member in the past year. The manager acted promptly, appropriately, and in line with the home’s policy, in reporting the allegation to social services, the police and to the CSCI. A thorough investigation was carried out: this fully exonerated the member of staff. Another allegation, that a visitor was financially exploiting a resident, was also reported as above. The resident chose not to pursue the issue. The home has a detailed policy for the management of challenging or violent behaviour. It aims to prevent or limit such behaviour by careful assessment and good care practices. It allows for physical intervention by staff only to prevent a resident harming his- or her-self, or another resident(s); or when a staff member is in actual physical danger and is unable to withdraw. No such episodes have occurred. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 20 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, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a safe environment, but there is an outstanding maintenance issue (re-carpeting). Bedrooms are safe, comfortable and nicely personalised, but some armchairs need replacing. The home is clean, pleasant and hygienic, but easily cleanable furniture has yet to be supplied in all areas of the home. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 21 EVIDENCE: Safe environment: The home has a location and layout is suitable for its stated purpose. It is accessible, safe and generally well maintained. It is comfortable and reasonably homely. However, the manager was not able to demonstrate that the company has fully implemented previous requirements regarding the building (see standards 24 and 26, below). A requirement is made. Furniture and Fittings: It was a requirement of the last inspection report that the registered person provides an action plan for replacement of the carpets identified; provides an action plan for replacement of armchairs; investigates the smell in the visitor’s toilet; and replaces old and faded sheets and duvet covers. This has been partly carried out. The issues with the toilet and the sheets and duvet covers have been resolved. However, the dining room carpet and the armchairs have yet to be replaced. A requirement is made. It was noted that the company has applied to North Tyneside Council for a capital grant to cover improvements such as the replacement of furniture and floor coverings. A decision has yet to be received. Hygiene and Control of Infection: It was a requirement of the last inspection report that registered person replaces the stained urinals; ensures that staff have access to ample supplies of paper hand towels; and ensures that all furniture used is of a type intended for commercial use and can be easily cleaned. This has been partly carried out. Urinals have been replaced and there are ample supplies of paper hand towels. The issue of easily cleanable furniture is still outstanding. A requirement is repeated. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 22 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): Standards 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are enough staff, including registered nurses, to meet the needs of the residents. Not enough of the care staff are qualified. Some aspects of the home’s recruitment practices need to be tightened up, to fully protect the residents. Staff are being given the basic training necessary to do their jobs, but individual staff training needs are not being identified and met. EVIDENCE: Staff Complement: The staff rotas were studied. The home continues to be adequately staffed, and meets both the residents’ needs and the required minimum staffing levels. On the day of this inspection, the home had 34 of its 46 beds occupied. The staffing levels were therefore below the agreed minimum level for when the home is full. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 23 The staffing was as follows: 8am to 2pm: 2 first level nurses and 5 carers. 2pm to 8pm: 2 first level nurses and 4 carers. 8pm to 8am: 2 first level nurses and 2 carers. (These staffing levels are below the agreed minimum level There is a full-time domestic housekeeper plus 120 hours domestic cover each week, available between 8am and 4pm daily. There is a full time (48 hours per week) chef, with a kitchen assistant between 10am and 6pm, daily. Staff Qualifications: It was a recommendation of the last inspection report that the registered person ensures that at least 50 of the care staff are trained to National Vocational Qualification (NVQ) level 2 in care. This has not been carried out. Due to staff turnover, a number of staff qualified to NVQ level 2 have left, meaning that there is currently only 44 of care staff with this qualification. Another four staff are due to start working towards this qualification. When qualified, this would bring the percentage over the required 50 again. A recommendation is made. Staff Recruitment: Study of the recruitment and selection records on the personnel files of three carers raised a number of concerns. Full Criminal Record Bureau (CRB) disclosure forms are not being held in the home for inspection purposes (a record of the CRB reference number, only, was available). This means that there was no opportunity to discuss any issues raised by such checks with the home’s manager. A requirement is made. There were two examples seen of ‘testimonials’ being accepted without any subsequent checking by the home. One was in lieu of a reference, another covering a person’s employment history. This is unacceptable as being open to abuse. A requirement is made. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 24 Study of the records of induction training showed that the whole induction programme was completed in one day. Clearly, no meaningful induction programme can be completed in such a short space of time. A requirement is made. It was recommended to the manager that the interview checklist is amended to include a ‘prompt’ to ensure that all areas of the job application are fully completed; and to record where anomalies such as gaps in employment histories have been discussed or otherwise investigated. Staff Training: It was a requirement of the last inspection report that the registered person keeps statutory training up to date; and trains the staff in Dementia Care. This is in the process of being carried out. Study of the mandatory training matrix showed that all staff have now had moving & handling training; and all had either had, or are booked to receive, fire safety training. Kitchen staff have had basic food hygiene training; care staff will be receiving food awareness training. Domestic staff have had Control of Substances Hazardous to Health (COSHH). A programme of Protection of Vulnerable Adults (POVA) training has just started. All staff are planned to have had this training by the end of December. A first aid training course is being arranged. The manager has completed a Health & Safety course. Advanced care plan training is taking place, to improve the care of residents at the point of death. This is good practice. There was no evidence that staff are having an individual training needs analysis undertaken as part of their annual appraisal. Therefore, it was not possible to judge whether all staff training needs are being identified and/or met. A requirement is made. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 25 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, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is a first level nurse, who is suitably qualified and experienced to run the home. The home is well managed. The home is generally run in the best interests of the residents. Residents’ financial interests are safeguarded. Staff receive regular supervision, but have not had an annual appraisal of their work this year. The health and safety of the residents and of the staff are promoted and protected. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 26 EVIDENCE: Day-to-Day Operations: The manager is a first level registered nurse. She has been assessed by CSCI as being a fit person to carry out the duties and responsibilities of her role. She has over three years experience as a manager. She holds the Registered Manager Award (RMA). The manager has made good improvements to the home in the past years. Quality Assurance: The manager carries an internal audit of the home’s operations every month. This audit covers a wide range of areas, including environment, medications, care documentation, complaints, training, supervision and health & safety. The manager describes it as a useful tool, and it is obviously taken seriously. There was evidence that actions are being taken to address any quality deficits identified. Examples of this were seen, including the need for more regular supervision, which has now been put into practice. Unfortunately, the audit does not include asking the views of the residents and their relatives, which is the central theme of this particular standard. A requirement is made. The manager is currently drawing up an annual development plan. Service Users’ Money: The company has recently changed its system of recording and holding residents’ money. The new system is fully computerised, with both the cash and receipts being kept in a central ‘pot’, rather than holding each resident’s cash in separate zipped wallets. This was said to be a ‘half-way’ position to the ‘on-line banking’ system, with individual interest-bearing accounts, that the company is planning to implement. The cash held was checked against the account balance and was correct. The company’s regional Administrative Manager recently carried out a full audit of the home’s finances. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 27 Staff Supervision: Supervision records show that the home is meeting the required regularity of staff supervision (that is, six times per year). The chart shows both the planned and (where different) the actual date of each staff member’s supervision. None of the nine senior staff involved in providing staff supervision have been given any training in this. As feedback indicates that some senior staff have reservations as to their personal skills in this important area, a requirement is made to this effect. Staff annual appraisal has not been conducted in the past year. A requirement is made. The manager must be provided with the skills to conduct annual staff supervision. A requirement is made. Safe Working Practices: It was a requirement of the last inspection report that the registered person ensures that all health and safety checks are up to date. This has been carried out. A ‘maintenance records book’ has been introduced. This is extremely comprehensive and requires monthly checks in all areas of health and safety. It is completed by the maintenance officer, and overseen by the manager, who also carries out spot checks. The manager is due to start a three-day health & safety course in October, and will then become the named health & safety officer for the home. Minutes of the most recent health & safety meeting, attended by the manager, deputy manager and cook, with apologies from the housekeeper and maintenance officer, were displayed on the notice board. Accident records are completed in good detail. There is a monthly audit of accidents and anecdotal evidence of trends being identified and remedial actions taken. The fire logbook is kept to the same high standard. An emergency fire/evacuation bag has recently been introduced. This contains a torch and batteries, fluorescent fire marshals’ waistcoat, an ‘emergency procedure folder’ with evacuation and relocation plans, essential service user information, and 20 pence pieces for the telephone. This is very good practice. Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 28 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 2 X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 4 Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 29 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 OP12 Regulation 16.2 Requirement Each resident must have a detailed assessment of his or her individual social needs, wishes and interests. From this assessment, each resident must have an individual plan of social care drawn up that properly reflects information from the assessments. 2. OP12 16.3 Each resident must have a detailed assessment of his or her individual spiritual needs, wishes and interests. Where such needs have been identified for a resident, an individual plan of spiritual care must be drawn up that properly reflects information from the assessment. 3. OP12 16.2 A more regular and varied group social activities programme must be introduced. The dining room carpet must be replaced. DS0000069661.V342325.R01.S.doc Timescale for action 30/11/07 30/11/07 30/09/07 4. OP19 16.2 30/11/07 Stephenson Court Nursing Home Version 5.2 Page 30 5. 6. OP24 16.2 16.2 Worn armchairs must be replaced. All furniture must be of a type intended for commercial use and can be easily cleaned. Full Criminal Record Bureau (CRB) disclosure forms must be held in the home for inspection purposes. The home must not accept ‘testimonials’ in place of references taken up directly by the home. Induction training must be given at a rate that allows the new staff member to absorb and understand all areas of the training. 30/11/07 30/11/07 OP26 7. OP29 19.4 31/08/07 8. OP30 18.1 An individual training needs analysis must be undertaken as part of each staff member’s annual appraisal. Identified training needs must be met within a reasonable timescale. 31/12/07 9. OP33 24.3 The home’s quality assurance and quality monitoring systems must be based on asking the views of the residents and their relatives as to the service being received. All staff involved in supervising other staff must be given appropriate training to carry out this role effectively. All staff must receive appraisal of their work on an annual basis. 31/08/07 10. OP36 18.1 31/12/07 Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 31 10. Cont inue d The manager must be given appropriate training in conducting annual staff appraisals. 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 OP28 Good Practice Recommendations A minimum of 50 of care staff should be trained to at least National Vocational Qualification (NVQ) level 2 in care, excluding those care staff who are registered nurses. The manager should ensure that the job interview checklist is amended to include a ‘prompt’ for checking that all areas of the job application are fully completed; and to record where anomalies such as gaps in employment histories have been discussed or otherwise investigated. 2. OP29 Stephenson Court Nursing Home DS0000069661.V342325.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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. 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