Inspection on 30/01/07 for The Mains Nursing Home

This inspection was carried out on 30th January 2007.

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

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

Other inspections for this house

The Mains Nursing Home 26/01/06

The Mains Nursing Home 07/06/05

The Mains Nursing Home 23/09/04

The Mains Nursing Home 25/05/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE The Mains Nursing Home Drovers Lane Redmarshall Stockton-on-Tees TS21 1ER Lead Inspector Ania Swann Key Unannounced Inspection 30th January 2007 09:45 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.V328235.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. The Mains Nursing Home DS0000000213.V328235.R01.S.doc Version 5.2 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 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.V328235.R01.S.doc Version 5.2 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. 26th January 2006 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 single bedrooms, 17 of which have en-suite facilities, and four double bedrooms also with en-suite 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 current fees range from £353 per week for residential care to £353 Nursing Banding for residents requiring nursing care. The Mains Nursing Home DS0000000213.V328235.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection lasting over eight inspection hours in total. The inspector spoke to three residents, two relatives and three members of staff on the day of the inspection. There were also discussions with the acting manager and the registered providers. A range of documents and records were looked at, including staff recruitment and training files. Nine completed relative/visitor comment cards and ten completed service user surveys were returned to the inspector. A tour of the premises also formed part of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The registered persons must ensure that recruitment policies and procedures are put into practice for all new members of staff to ensure the residents are protected and cared for by appropriately qualified staff. The registered persons must ensure that the health and safety of all the residents is maintained at all times, and that staff are vigilant and carry out risk assessments where necessary. The Mains Nursing Home DS0000000213.V328235.R01.S.doc Version 5.2 Page 6 Medication procedures need to be followed fully to safeguard the residents from possible errors. The manager should ensure that each resident has an individual care plan in place based on a full assessment of needs. This care plan should be reviewed regularly to monitor any changing needs of the resident. Staff supervisions and appraisals should take place to make sure that residents are being cared for appropriately and that all the homes training is being put into practice. 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. The Mains Nursing Home DS0000000213.V328235.R01.S.doc Version 5.2 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.V328235.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the information they need to make an informed choice about the home. A contract is given to the resident or their representative. The resident has his/her needs assessed prior to moving into the home and prospective residents and their families get the opportunity to look around the home and have a trial visit. The Mains Nursing Home DS0000000213.V328235.R01.S.doc Version 5.2 Page 9 EVIDENCE: The statement of purpose sets out the objectives and philosophy of the home, but needs updating and amending, as there has been a change of manager. The residents guide is given to residents before moving in, and provides clear information about the home. The guide is very resident focused and invites input from the residents; “This is your home, and we require your input to keep it that way”. A contract is given to each resident with the terms and conditions. This sets out in detail what the resident can expect. The residents confirmed to the inspector in the service user surveys and in discussions with the inspector, that they had received a contract. Four residents files were looked at and showed evidence of a full assessment done through Care Management with a care plan produced for care management purposes. Residents who spoke to the inspector said they or their relatives had looked round the home and visited prior to moving in. The Mains Nursing Home DS0000000213.V328235.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all the residents have an individual care plan in place. The manager should ensure that each residents health, personal and social care needs are documented fully. The resident’s health care needs are being met. The policies and procedures for dealing with medication are not fully put into practice. Residents are treated with respect and their privacy is maintained. The Mains Nursing Home DS0000000213.V328235.R01.S.doc Version 5.2 Page 11 EVIDENCE: The four residents files the inspector looked at had gaps in the information or no care plan evident. The care plans that were present did not contain enough individual information and need to be developed further. There is evidence to show that the residents health care needs are being met. A resident told the inspector “the staff meet my needs in every way. If you’re poorly the doctor is brought in”. Another resident said “on the whole I am well cared for”. The service user surveys also confirm that residents feel that they receive the medical support they need. The home has policies in place for the safe ordering, storage, administration, monitoring and disposal of medication. Controlled drugs are appropriately stored and recorded but the manager should ensure that there is a regular audit of the controlled drugs and that this is documented. The inspector looked at resident’s medication records. Medication records were signed for where medication had been given, but where medication had been omitted for a reason, this was not specified on the administration sheet. Where drugs are given ‘as required’, the time needs to be recorded on the medication record so that it prevents the residents being given more medication too soon. The home has a double room policy stating that “a room will only be shared if both residents have made a positive choice to share with each other”. A tour of the premises showed that there are appropriate means to ensure the privacy of residents in shared rooms. The residents the inspector spoke with confirmed that they are happy with the way that staff deliver their care and respect their dignity; “the staff always respect my privacy – always knock if the door is closed”. The Mains Nursing Home DS0000000213.V328235.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social, cultural and recreational activities meet resident’s expectations. Residents maintain contact with their family and friends and the home makes them feel welcome. The residents are helped to have choice and control over their lives. The home provides a healthy, varied diet at times convenient to them. EVIDENCE: The residents have the opportunity to exercise their choice in relation to activities, meals and routines. The inspector observed one resident having her breakfast at 10.30 because she chose to have it then. The service user surveys confirmed that activities take place in the home, but that some of the residents choose not to take part. There is a notice board in the entrance of the home where the menu, activities and staff on duty that day can be entered. The Mains Nursing Home DS0000000213.V328235.R01.S.doc Version 5.2 Page 13 On the day of inspection this had not been filled in and was blank. This could be used by the staff to display information, and bring attention to activities taking place. The residents confirmed that social events take place regularly, and that families and friends are invited to attend. Family and friends feel welcome and know that they can visit the home at any time. The design of the home has seating areas within the communal areas where residents can entertain their visitors, in addition to the privacy of their own home. On the day of inspection, a relative who visits the home regularly was observed having a meal with his wife. Residents were observed having lunch, and the food was nicely cooked and well presented. A resident told the inspector “the meals are very, very good. If there is anything you don’t like they get you something else”. There was however no menu on display anywhere in the home. The board in the entrance of the home could be used more for this purpose. The cook does consult the residents about what they want to eat, and told the inspector that she will offer an alternative to the main meal if the resident does not like what is on offer. The Mains Nursing Home DS0000000213.V328235.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to a robust, effective complaints procedure and are protected from abuse. EVIDENCE: The Mains has a comprehensive complaints policy and this is evident on the wall in each resident’s bedroom. There is also a copy in the resident’s guide. Residents demonstrate a good understanding of how to make a complaint and who to speak to. Discussions with staff confirm that they are aware of what to do if they have any concerns or complaints. Residents and visitors told the inspector that they are happy with the service and feel safe. Staff confirmed that they know the procedure to follow if they suspect abuse is taking place. Staff records show that some staff have not had training in the protection of vulnerable adults. The inspector acknowledges that this is scheduled to take place, but the registered person should ensure that it does. The Mains Nursing Home DS0000000213.V328235.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Mains provides a homely environment where residents own rooms suit their needs and they have their own possessions around them. The home is clean but could benefit from further investment to improve the environment. EVIDENCE: A tour of the premises highlighted a rolling programme of redecoration of some of the bedroom areas. The dining area is dark and could be improved for the residents by redecoration and better lighting. There are plans to replace the flooring in the shower room downstairs. Residents can personalise their own rooms and are encouraged to bring in their own possessions and furniture. The Mains Nursing Home DS0000000213.V328235.R01.S.doc Version 5.2 Page 16 The Mains has two lounges downstairs which provide the residents with a homely communal environment. One of the lounges is designated as a quiet lounge where residents can enjoy a good selection of books that are changed regularly from the mobile library that visits. The home is generally clean and tidy, but staff should ensure that bins are emptied regularly and clinical waste bins are covered with a lid at all times. The home was free from offensive odours. The home has recently purchased new laundry equipment that ensures that laundry is washed at appropriate temperatures. On the day of inspection one of the ground floor fire exits and a fire extinguisher, was noted by the inspector to be partially obstructed by a table. The management recognised the potential risk and took prompt action to move the table. The Mains Nursing Home DS0000000213.V328235.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by the numbers and skill mix of staff, but residents would benefit from additional staff on duty. The service has a recruitment practice that is adequate and generally meets the regulations, but there are shortfalls in the process. The registered persons must ensure that residents are protected fully by a thorough recruitment procedure for all staff. Staff are trained and competent to do their jobs but the registered persons should ensure that training is updated and that all staff receive the training to equip them to meet the needs of the residents and maintain the safety of staff and residents. The Mains Nursing Home DS0000000213.V328235.R01.S.doc Version 5.2 Page 18 EVIDENCE: The staff duty rota shows that there is a registered nurse on duty for every shift including nights. On the day of inspection, the manager was observed to be working caring for the residents. The manager confirmed that she usually works “on the floor” and is therefore limited to the amount of time she has to undertake her duties as manager. Half of the service user surveys received by the inspector state that they feel the staff are usually available when you need them. Residents told the inspector “the staff are very good to me here” and “on the whole I am well cared for”. One of the relatives comments “staff resourcing is often stretched”, and half the relative comment cards indicated that in their opinion there are not always sufficient numbers of staff on duty. A care worker told the inspector that “I feel that the residents get the care they need and overall there are enough staff to care for the residents”. Fifteen staff have achieved NVQ level 2 and the registered persons confirmed that there are eight staff still to do the training. Four staff files were examined, including the acting manager. All the files had references and employment records, but one of the files of a qualified nurse did not have evidence of a current registration, and for another staff member there was no evidence of checks having been undertaken of the Protection of Vulnerable Adults and Nursing and Midwifery Council registers. The registered persons must ensure that all new staff are confirmed in post only following completion of satisfactory checks, to ensure that residents are protected and safe. The files show evidence that staff receive a comprehensive induction training. Staff receive training in first aid, fire awareness, manual handling and protection of vulnerable adults. Files show that some of this training is expired and requires a refresher course. The registered persons confirmed that there are some staff who require training in these areas. The inspector acknowledges that there are plans to do this. The Mains Nursing Home DS0000000213.V328235.R01.S.doc Version 5.2 Page 19 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): 31, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Mains is managed by a person who is appropriately qualified and experienced to meet the purpose, aims and objectives of the home, however, she must be given the opportunity to discharge her responsibilities fully. The home is run in the best interests of the residents, and their financial interests are safeguarded. The home has procedures in place to provide supervision arrangements, but the manager should ensure that these are put into practice. The safety and welfare of residents is not protected fully. The registered persons must ensure that the home provides and maintains the safety of all its residents. The Mains Nursing Home DS0000000213.V328235.R01.S.doc Version 5.2 Page 20 EVIDENCE: There has been a change of manager since the last inspection. The current manager is a qualified nurse and has recently completed her NVQ Level 4 Registered Managers qualification. Discussion with the manager highlighted the need for the manager to have time to fulfil her duties as manager balanced with working as one of the staff team caring for the residents. The manager is aware of the areas where they need to make improvements, and the inspector acknowledges that there are plans to undertake the work. The home does seek out the views of the residents and their families by questionnaire. There have been residents meetings in the past, but there is no evidence of any having taken place since the new manager took over. This was confirmed by one of the residents who has been living in the home for a few months. The manager has an action plan to review all the documentation and quality assurance but she needs to ensure that this is completed. The manager is responsible for the resident’s personal allowances. A sample of the records and receipts of transaction show that there is a good system in place and that the resident’s money is secured appropriately for safe-keeping. There was no evidence of staff having received formal supervision in the last six months. The manager confirmed that she has not yet undertaken any supervisions or appraisals of staff but has plans to do so. The manager must ensure that staff working in the home receive regular supervision that covers all aspects of practice and their career development needs. The staff have regular staff meetings and evidence was provided to the inspector that confirms a recent meeting. During a tour of the premises, the inspector discovered that the safety of one of the residents was compromised. The windows in an upstairs bedroom did not have secure window restrictors in place and the inspector was able to open them fully. The registered person did act immediately and secure a temporary fixing to safeguard the resident, but the service must continue to ensure that there is provision and maintenance of window restrictors, based on assessment of vulnerability of and risk to service users. The manager does acknowledge that there are improvements to be made but she does have a commitment to undertaking the work. Discussion with the registered persons and the manager confirmed to the inspector the service is resident and family focused, and that they are aware of the need to develop the areas highlighted in this report. The Mains Nursing Home DS0000000213.V328235.R01.S.doc Version 5.2 Page 21 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 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 2 x 3 3 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 2 x 2 The Mains Nursing Home DS0000000213.V328235.R01.S.doc Version 5.2 Page 22 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. 1. Standard OP7 Regulation 15 Requirement The registered persons must ensure that each resident has a care plan in place, based on a comprehensive assessment, that identifies individual needs and is reviewed monthly. The registered persons should ensure that staff record the administration of medication appropriately, particularly where drugs have been omitted or drugs have been given ‘as required’. This will minimise the potential for error. New staff are confirmed in post only following completion of a satisfactory check of the POVA and NMC registers. The registered persons must ensure that this takes place for all the staff including the manager in order to ensure the protection of the residents. The registered persons should ensure that staff working at the home are appropriately supervised, including direct observation, in order to maintain and improve the quality of care DS0000000213.V328235.R01.S.doc Timescale for action 28/02/07 2. OP9 13 01/02/07 3. OP29 9, 19 (Sch 2) 01/02/07 4. OP36 18, 24 30/04/07 The Mains Nursing Home Version 5.2 Page 23 5. OP38 13, 23 for the residents. The manager should ensure that supervision arrangements are put into practice. The registered persons must ensure the health and safety of all its residents. There must be provision and maintenance of window restrictors, based on assessment of vulnerability of and risk to residents. Risk assessments should be undertaken and all staff to be aware of the potential risks. 30/01/07 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. 2. Refer to Standard OP19 OP33 Good Practice Recommendations The service could improve the lighting and décor in the resident’s dining room to make it comfortable, sufficiently bright and enjoyable for the residents. The views of the residents should be sought, and feedback obtained about the service being provided, in regular residents meetings. The Mains Nursing Home DS0000000213.V328235.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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. Extracts may not be used or reproduced without the express permission of CSCI The Mains Nursing Home DS0000000213.V328235.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!