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Inspection on 26/01/06 for The Mains Nursing Home

Also see our care home review for The Mains Nursing Home for more information

This inspection was carried out on 26th January 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents and a relative said they were very satisfied with the care they receive. A relative commented in a questionnaire `I am pleased with Mam`s location and the standard of care from a very caring staff`. The home has a stable staff group, which ensures consistency of care for the residents. The induction training is thorough and comprehensive.

What has improved since the last inspection?

Staffs have received more training and since the previous inspection they have undertaken courses in Risk Assessment, Intermediate Food Hygiene, Health and Safety, Adult Protection and Fire Safety.

CARE HOMES FOR OLDER PEOPLE The Mains Nursing Home Drovers Lane Redmarshall Stockton-on-Tees TS21 1ER Lead Inspector Val Daly Unannounced Inspection 26th January 2006 09:30 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 The Mains Nursing Home DS0000000213.V267519.R01.S.doc Version 5.1 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. The Mains Nursing Home DS0000000213.V267519.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Mains Nursing Home Address Drovers Lane Redmarshall Stockton-on-Tees TS21 1ER 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) 01740 630017 Mr Paul Glen Dowell Mrs Teresa May Dowell Mrs Alison Clare Pemberton Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places The Mains Nursing Home DS0000000213.V267519.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. That a maximum of two places may be used at any one time for accommodation of persons who are 55 years and over with a physical disability. 7th June 2005 Date of last inspection Brief Description of the Service: The Mains is a thirty-one bedded care home registered to care for residents requiring nursing or personal care. The home is located in the small village of Redmarshall. The accommodation consists of 21 single bedrooms, 17 of which have en suite facilities and four double bedrooms also with ensuite facilities. There is a stair lift for those residents who have need of it. There are facilities available for the residents to see family, friends and visiting professionals in private. The Mains Nursing Home DS0000000213.V267519.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection commenced at 10.00 am and lasted for three hours. Three residents, a relative, staff and the manager were spoken to during the inspection. Numerous records including staff recruitment files, medication records, staff training, policies and procedures were examined. A partial tour of the home was carried out. Three residents were spoken to during the inspection; one commented that ‘all the girls are friendly and always seem to be offering food and drinks’. Another resident described how staff would ‘pop in her room to check she was alright but they would always knock on the door first’. A relative said that ‘nothing seems to be a trouble for the staff’. What the service does well: What has improved since the last inspection? What they could do better: Whilst carers are in the process of undertaking NVQ training more are required to complete the training. This will ensure the home meets the required 50 of carers who are qualified in NVQ. More staff requires training in First Aid. The Mains Nursing Home DS0000000213.V267519.R01.S.doc Version 5.1 Page 6 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 Mains Nursing Home DS0000000213.V267519.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Mains Nursing Home DS0000000213.V267519.R01.S.doc Version 5.1 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 the following standard(s): 6 The home does not provide this service. EVIDENCE: The home does not provide intermediate care. The Mains Nursing Home DS0000000213.V267519.R01.S.doc Version 5.1 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 the following standard(s): 9 The homes procedures for storing and administering medication are robust to safeguard the residents. EVIDENCE: Policies and procedures are in place for the ordering, receipt, storage, disposal and administration of medication. Examination of medication administration records showed that the procedures were being followed. At the time of the inspection there were no residents who managed their own medication. The Mains Nursing Home DS0000000213.V267519.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 14 Residents are encouraged to make positive choices about how they spend their day. EVIDENCE: There is a communion service every month and a local priest also visits residents regularly. Three residents were spoken to during the inspection. They preferred to spend the day in their rooms. However they all said that staff were always ‘popping in and out to ensure they were alright’. There is musical entertainment every month and the residents spoken to felt that this was enough for them. In house activities are available if residents wish to join in. The Mains Nursing Home DS0000000213.V267519.R01.S.doc Version 5.1 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Staffs have received training in adult protection issues, which helps to protect the residents. EVIDENCE: There is an ongoing training programme in the home and staff training records showed that training had been received in adult protection. The home has policies and procedures to follow to protect the residents in case of suspected abuse. The Mains Nursing Home DS0000000213.V267519.R01.S.doc Version 5.1 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These eight standards were not assessed at this inspection. EVIDENCE: The Mains Nursing Home DS0000000213.V267519.R01.S.doc Version 5.1 Page 13 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 procedures for the recruitment of staff are robust and provide the safeguards to offer protection for people living in the home. The deployment and number of staff ensures that the residents are supported by an experienced group of staff. EVIDENCE: When completing the rotas the manager balances out the more experienced and qualified staff with junior staff. The home has a policy and procedure in place for the recruitment of staff. Staff records showed that the required information, references and CRB checks were in place prior to staff commencing work in the home. Staffs undertake a full induction programme, which includes watching videos in areas such as Health and Safety, Principles of care, Infection Control. Staffs are then required to complete questionnaires to ensure they have understood the contents of the videos. A further training programme for staff is in place. Since the previous inspection staff had undertaken training in many areas such as NVQ 2, Adult Protection, Fire Safety, Risk Assessment. However whilst a further eight staff have commenced NVQ training more carers need to have completed NVQ training for the home to reach the required 50 of carers with the qualification. There is a ‘First Aider’ on duty on each shift in the home, however more staff require training in First Aid. The Mains Nursing Home DS0000000213.V267519.R01.S.doc Version 5.1 Page 14 There was evidence to show that staff receives formal supervision every eight weeks. The Mains Nursing Home DS0000000213.V267519.R01.S.doc Version 5.1 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 33, 35 & 38 The manager offers clear leadership to the staff so that they can meet the needs of the residents. Views of the residents are sought so that they can contribute to the development of the service. The health and safety of the residents is promoted. EVIDENCE: The manager has undertaken and completed NVQ level 4 and the Registered Managers Award. An annual quality assurance audit is carried out involving residents and relatives. Following the audit the manager compiles and works through an action plan. The manager also carries out monthly audits in the kitchen, housekeeping and a three monthly audit of the medication. The home has health and safety policies and procedures in place. Staff training files examined showed that training for health and safety takes place. The Mains Nursing Home DS0000000213.V267519.R01.S.doc Version 5.1 Page 16 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Mains Nursing Home DS0000000213.V267519.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? No. 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. Standard Regulation Requirement Timescale for action 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 OP2828 Good Practice Recommendations A minimum of 50 of carers should achieve NVQ level 2 or above. The Mains Nursing Home DS0000000213.V267519.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 The Mains Nursing Home DS0000000213.V267519.R01.S.doc Version 5.1 Page 19 - 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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