Care Home: Netherclay House

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What the care home does well People were complimentary about the kindness of the staff one person said that` people are very kind` and another said that `You cant fault the staff`. One staff member said that the home` Treats every resident as an individual with a huge amount of care and affection`. The company have been proactive in ensuring that the service is effectively managed in the absence of a registered manager. Each person at the home has a care plan. This plan outlines the preferences of the person and an agreed plan of care is in place to support both preferences and any specific care needs. All records are maintained confidentially. Activities are provided and people have the choice if they wish to participate. People told us they were happy with the activity provision. The home has an updated complaints procedure and appropriate steps have been taken to prevent the people using the service from being at the risk of abuse. The homes environment is comfortable; there is suitable communal space with a comfortable lounge and dining area in each home. Staffing levels at the home are adequate to meet the people`s needs. Staff training is in place to support the needs of people using the service.Health and Safety measures are in place to promote protection and policies and procedures are in place to ensure good practice. What has improved since the last inspection? The registered provider has updated the homes statement of purpose, service user guide and terms and conditions of residency to reflect any environmental limitations to access to the lounge areas and variance in fees The registered provider now ensures that pre admission assessments are completed in sufficient detail to ensure that the home can provide prior to admission the care needs identified. Furthermore, the registered provider has provided staff training to ensure that a plan of care is in place for each person using the service which is fully completed, regularly updated and contains all the relevant detail for each identified need. The medication systems have been addressed to meet all of the requirements made at the last key inspection. The homes policies for abuse awareness and safeguarding vulnerable adults is in line with the regional policy and is available to staff. The environmental issues raised about locks being available on doors and radiator guards have been addressed and risk assessments are in place where required. Regular reviews of dependency levels take place and staffing levels adjusted to reflect that dependency. This has resulted in an increase in night staff. A system is now in place to ensure that all personal monies are regularly audited and checked to maintain an accurate record. All areas previously identified with reference to health and safety and including the storage of substances hazardous to health in line with the COSHH guidance have been addressed. What the care home could do better: The registered provider is recommended to further develop care plans to include all aspects of identified need. This is with reference to people who have challenging behaviour and specific care interventions to ensure that staff have sufficient information to meet peoples identified needs. The registered provider is recommended to ensure that staffing levels are consistent to the calculated dependency levels to ensure that there are sufficient staff available at all times to meet the needs of people using the service.The registered provider is recommended to ensure that all prospective employees provide a detailed employment history which includes dates of previous employment. This is recommended to ensure that there is no risk to people using the service. Furthermore, the registered provider is recommended to ensure that a record of interviews is maintained to provide a clear recruitment audit and a record is recommended to be maintained of how staff are supervised having received a POVA check but are awaiting a CRB check. The registered provider is recommended to ensure that quality assurance monitoring is provided to include the surveyed opinions of all people who use the service. This is to ensure that the service is monitored and developed to meet the needs of people using the service. The registered provider must ensure that staff receive supervision no less than 6 times per year and that the topics discussed are in line with the National Minimum Standards. This is required to monitor and promote good practice. The registered provider is recommended to ensure that all accidents are recorded. Accident audits are recommended to be further developed to identify trends and repeated incidences to promote accident prevention. CARE HOMES FOR OLDER PEOPLE Netherclay House Bishops Hull Taunton Somerset TA1 5EE Lead Inspector Gail Richardson Unannounced Inspection 18th December 2008 10:00 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 Netherclay House DS0000016043.V373402.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. Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Netherclay House Address Bishops Hull Taunton Somerset TA1 5EE 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) 01823 284127 01823 336765 Mr Peter Howard Wilmot-Allistone MRS LAURA WILMOT-ALLISTONE Manager post vacant Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named service user under the age of 65 years. Rooms 14, 15 and 16 are suitable only for service users who have a degree of physical and mental independence. The Manager must conduct regular assessment and review of service user needs, to ensure that the accommodation and service provided continues to be appropriate. 1st July 2008 Date of last inspection Brief Description of the Service: Netherclay House is a Georgian building with modern extensions that has been a residential home since 1972. The Registered Providers at this time are Mr and Mrs Wilmot-Allistone however Mr Patrick Allistone and Mr Richard Allistone are described in the homes documentation as partners and Care Director Jo Girdler oversees the home on their behalf. The Registered Managers position is currently vacant but the home has a Manager Designate in post. The home is registered with the Commission for Social Care Inspection to provide personal care to up to 42 people over the age of 65 years. The home provides accommodation for up to thirty-seven people within the main building, and a further five people within the bungalows set in the grounds. There are some environmental limitations relating to disabled access to parts of the home. The home provides meals to persons in their own home as part of the providers Domiciliary Care Agency. Day care is also provided for up to two people per day, which is not registered or inspected by CSCI. Netherclay House currently offers day care, respite care and permanent accommodation. The home does not provide nursing care. Netherclay House is set in large gardens that border the River Tone. The current fee range is £375.00 to £550.00 per week. This fee depends on the size of room and does not include hairdressing, private phone installation and calls, accompanied outings, toiletries, dry cleaning, electrical equipment tests and chiropody. Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This was an unannounced inspection, which took place over 1 day (5 hours) on the 18th December 2008 by Regulation Inspector Gail Richardson and Regulation Inspector Alison Philpott. For the purposes of this inspection the term ‘we’ will be used when referring to the commission. As part of the inspection process CSCI are using Experts by Experience to help inspectors get a picture of what it is like to live in a social care setting. The term Expert by Experience used in this report describes the people who also visited the home during the inspection and who have knowledge about social care. A tour of the home took place and a selection of the bedrooms and all communal areas were seen. There were 34 people currently residing at the home receiving personal care and one person was in hospital. Some people were receiving respite care for an agreed shorter period of time. The homes last key inspection raised some areas of concern and requirements were made. Following this inspection the registered provider submitted an improvement plan to the Commission, which identified how they would improve the service. This was received by the Commission within agreed timescales and the Commission met with the provider and members of the company’s senior management team to discuss the company’s plans for improvement. The company have implemented improvements in line with their improvement plan and have liaised closely with the Commission during this period. The company have been proactive in addressing all requirements and have demonstrated their commitment to improving the quality of the service provided. A random inspection was undertaken in November 2008 by the Regional Pharmacist to review requirements made regarding medication systems at the last key inspection. The report showed that considerable work had been undertaken to improve the systems in place and ensure the safety of people using the service. The inspector spoke to 10 people using the service and 7 members of staff. Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 6 As part of this inspection the inspector surveyed the opinions of a random selection of people using the service and Care Workers. 8 surveys were received from people using the service and 3 surveys from staff. The inspector spent time talking to people within the home and staff and observed that on the day of inspection, Records relating to care including 5 care plans, 4 staff files, finances and health and safety records were examined The focus of this inspection visit was to inspect relevant key standards under the CSCI ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are; - excellent, good, adequate and poor. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: People were complimentary about the kindness of the staff one person said that’ people are very kind’ and another said that You cant fault the staff’. One staff member said that the home’ Treats every resident as an individual with a huge amount of care and affection’. The company have been proactive in ensuring that the service is effectively managed in the absence of a registered manager. Each person at the home has a care plan. This plan outlines the preferences of the person and an agreed plan of care is in place to support both preferences and any specific care needs. All records are maintained confidentially. Activities are provided and people have the choice if they wish to participate. People told us they were happy with the activity provision. The home has an updated complaints procedure and appropriate steps have been taken to prevent the people using the service from being at the risk of abuse. The homes environment is comfortable; there is suitable communal space with a comfortable lounge and dining area in each home. Staffing levels at the home are adequate to meet the peoples needs. Staff training is in place to support the needs of people using the service. Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 7 Health and Safety measures are in place to promote protection and policies and procedures are in place to ensure good practice. What has improved since the last inspection? What they could do better: The registered provider is recommended to further develop care plans to include all aspects of identified need. This is with reference to people who have challenging behaviour and specific care interventions to ensure that staff have sufficient information to meet peoples identified needs. The registered provider is recommended to ensure that staffing levels are consistent to the calculated dependency levels to ensure that there are sufficient staff available at all times to meet the needs of people using the service. Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 8 The registered provider is recommended to ensure that all prospective employees provide a detailed employment history which includes dates of previous employment. This is recommended to ensure that there is no risk to people using the service. Furthermore, the registered provider is recommended to ensure that a record of interviews is maintained to provide a clear recruitment audit and a record is recommended to be maintained of how staff are supervised having received a POVA check but are awaiting a CRB check. The registered provider is recommended to ensure that quality assurance monitoring is provided to include the surveyed opinions of all people who use the service. This is to ensure that the service is monitored and developed to meet the needs of people using the service. The registered provider must ensure that staff receive supervision no less than 6 times per year and that the topics discussed are in line with the National Minimum Standards. This is required to monitor and promote good practice. The registered provider is recommended to ensure that all accidents are recorded. Accident audits are recommended to be further developed to identify trends and repeated incidences to promote accident prevention. 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. Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 9 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 Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 10 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 4 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes Service User Guide, Statement of Purpose and contract of residency have been amended to ensure that prospective people can make an informed decision about the home. All prospective residents receive a pre admission assessment by the Manager Designate. EVIDENCE: The home has in place a Service User Guide and Statement of Purpose to enable prospective people using the service and their relatives/representatives to make an informed decision about the home. These documents have been updated and amended to reflect the fee scale for each room and that fees may vary depending on room. The document also reflects the environmental Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 11 considerations needed prior to admission with reference to disabled access to the older part of the building. The management of the home explained that they are considering various options to enable access for everybody to all communal areas. We looked at three pre admission assessments and saw that they now contained sufficient detail to ensure that all needs had been identified. Surveys asked if people were asked if they wanted to move into the home and 8 said yes. All 8 people said that they got enough information about the home before moving in. One persons relative wrote that they ‘ Visited the home twice, then 2 staff came to see my relative at home to carry out an assessments of needs. They suggested which room would suit them’. Contracts were examined at this inspection contained details of terms and conditions or residency and included the fees charged for each room. Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service. Each person using the service has a care plan. The care plans have been improved and now provide sufficient detail to ensure that staff are aware of peoples needs and how to meet them. Staff were observed to treat service users with dignity and respect at all times and residents confirmed that they felt well cared for. Medication systems are in place to ensure the safety of people using the service. EVIDENCE: We looked at five care plans in detail. Following the last inspection considerable effort has been made to improve the care plans to ensure that all the required information to assist staff is available to form a working document. Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 13 The care plans seen clearly identified the areas of assessed need and a plan was in place for staff to follow to meet that need. These needs included any specialist care needs. We noted that one area of care planning required further development to ensure that people who exhibit any challenging behaviour have a clear plan of care available to staff to support both people using the service and staff. Risk assessments are in place to support people to maintain independence. A clear daily record is maintained for each person and the care plans had been signed by the person or their representative. There was a clear record of all visiting healthcare professionals visits and the outcome. Updated reviews were seen to take place regularly. The inspectors spent time observing the care being given and noted that the members of staff treated people using the service with dignity and respect at all times. On the day of the inspection people were very positive about living at the home and felt they were well cared for. People were asked if they made decisions about what they did each day. 6 people said always. One person commented ‘Mostly I can do what I feel up to doing’. The surveys asked if the staff treat them well. All 8 surveys said always. One person told us that ‘The girls are kind and friendly’. When asked if the carers listen and act on what you say, 5 people said always and two said sometimes. Comments received included ‘Mostly, if they can. The carers are always busy’ and ‘ most of the time’. The medication systems were satisfactory. There were no gaps evident in the Medication Administration Records, there was evidence of variable doses being recorded and hand transcribed entries being signed by 2 staff. People using the service have the option to self medicate should they want to and risk assessments are in place to ensure safe practice is maintained. Lockable storage is available as required. Requirements made at the previous inspection have all been addressed. Netherclay House DS0000016043.V373402.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): 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. There are opportunities for social stimulation and people are supported to join in with organised activities or pursue their own interests both in the home and in the community. The meals in the home are of a good quality and a range of choice is available. EVIDENCE: The home provides activities for both group and individual participation and maintains a record of if they participated. People told us that they joined in if they want to and they were happy with the level of activity provided. People were seen to be watching TV in their room or in the lounge and there was also an arts and crafts activity taking place in the dining room. A quiet library room is also available. One person told us that ‘ Many improvements have been made recently, especially with entertainment and there are more planned including furnishings and lighting’. Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 15 The Expert by Experience observed ‘Looking for evidence of activities, I found that there is a Social Activity Organiser who is present every afternoon from Monday to Friday and these activities are listed in a very well produced Newsletter with clear print and illustrations. This information was displayed at several points in the form of pages from the Newsletter. I was told that visitors are always made welcome and they, too, were happy that any concerns could be raised and would be listened to sympathetically. The activities noted in the newsletter were varied, people told us that they also have one to one visits from their key worker. The local clergy visit the home on a monthly basis to provide a religious service for people who wish to take part. People told us that within reason they could get up and go to bed when they wanted and that they could choose how they spent their day. The people using the service confirmed that they enjoyed the meals and that a choice is available. People told us there was always a choice and the cook explained that a staff member went round each morning to ask which choice people would prefer. Specialist diets are catered for and the home provides home cooked food from locally sourced retailers. Breakfast is served in the persons bedroom or the dining room, lunch is the main meal of the day and a lighter evening meal is served around 5pm. The Care Director advised us that the kitchen was visited by 26/1/09 by the Environmental Health Organisation & was rated as 5 stars. The Expert by Experience also said that ‘ Observing what happened at lunchtime, I noticed that food was served in a very professional manner. Most people were able to eat unaided but help was given to those who could not. Both sherry and wine were offered with the meal! The kitchen has recently received a 4-star rating for hygiene. ‘ Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 16 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 17 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are confident that they are listened to and their concerns and complaints acted upon. Staff demonstrated good knowledge and understanding of their role to ensure that people using the service are protected from abuse. EVIDENCE: The home has a complaints policy, which is displayed, in the home to enable access to all. On the day of inspection all people using the service who spoke with the inspectors, felt able to speak to the staff about any concerns and would feel confident that the issues would be dealt with in an appropriate manner. The home has no ongoing complaints; no concerns have been raised with the Commission about the management of the home. Surveys asked if people knew who to speak to if they were not happy? 8 people said yes. One person commented ‘my relative will talk to anyone and say if something’s bothering them’. 5 people told us they knew how to make a complaint and 1 did not. One person said ‘ it depends on the problem’. Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 17 The home now has a copy of the Safeguarding Adults in Somerset protocol (September 2008) which provides information to staff should an allegation be made. Staff training records confirm that all staff have received abuse awareness training and all staff have received a Criminal Record Bureau (CRB) check and Protection of Vulnerable Adults (POVA) check prior to commencing employment. All people using the service are registered to vote in any forthcoming elections. Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 18 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 22 23 24 25 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides people using the service with a clean and homely place to live, it is comfortable, clean and suited to needs of the people who live there. Some environmental restrictions regarding access to two lounges remain evident however we are advised that a new lounge for residents use is available which has full access for everyone. EVIDENCE: 6 people told us that the home was clean and fresh. One person told us ‘ The staff work tirelessly to keep the place clean and tidy’. The Expert by Experience observed that ‘Entering through the original house there is a definite “country house” atmosphere and the two lounges provide very pleasant seating areas – one with a television set and another smaller one on the other side of the hall with l tables and lots of books and games. The Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 19 newer part has been built to what I would judge to be a high standard to fit in with the existing building. ‘ ‘The grounds were quite extensive and well maintained with several individual sitting areas and my only criticism would be that in the area surrounding the sheltered accommodation, – some of the surfaces were a little uneven and slippery.’ The Care Director has informed us that a new lounge for residents use is available which has full access for everyone and the residents guide does reflect this change. The Expert by Experience also commented ‘One of the disadvantages of adding to an existing building was obvious in getting from the old house to the extension, which included the dining room, which involved negotiating three steps making access impossible for anyone in a wheelchair or with other mobility problems. The result is that people have to be taken out of the front door, across the front and around the side of the house and thence into the dining room. This is a relatively short journey but not pleasant on a rainy day or when it is very cold.’ Another person said that ‘The home is warm and comfortable and the staff are kind and caring’. A selection of bedrooms and all communal areas were seen at this inspection. The home is pleasantly decorated with décor and furnishings of a good standard, the home was clean and ongoing maintenance was evident. Bedrooms were personalised with peoples photographs and some small personal belongings and pieces of furniture and TV’s and call bells were available in each room including lounge areas. Some radiators were observed to be unguarded and may place people using the service as risk of injury, risk assessments are in place and plans to provide covers seen. Work has been undertaken to ensure that all bedroom have locks, which are accessible from the outside in an emergency. The home provides a designated outdoor smoking area for people using the service and an alternative designated area for staff. Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 20 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 good. This judgement has been made using available evidence including a visit to this service. The home employs enough staff to meet the needs of the people using the service and to ensure the safety, comfort and maintenance of the premises. People benefit from having trained staff that have a good understanding of their needs. EVIDENCE: On the day of inspection there were 6 care staff including a senior carer in the morning, the afternoon saw 5 care staff and 3 waking staff overnight. The level of staffing is now calculated to a dependency tool, which identifies the level of peoples needs. This has caused an increase in staffing level overnight. The staff rotas seen identified that for the two weeks beginning December 2008 there were 4 staff on each afternoon and each weekend had 5 staff on in the mornings and 4 on duty in the afternoon. The Regulation 26 reports supplied to the Commission by the provider state that staffing levels are consistent with 40 people using the service. The levels are recommended be reviewed to ensure that they are consistent. 2 staff told us that the induction to the job was done very well and one person said mostly. One staff member said that ‘Induction was very thoroughespecially for someone who had never worked in care before’. Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 21 One staff member told us that ‘Support of other staff members is invaluable, most despite being under pressure themselves have been very helpful’ One staff said that more staff would be ideal in order to be able to spend more time with individuals’. One staff member told us that sometimes handovers were not very good at explaining what had been happening. One staff also felt that more staff was needed. The care Director has advised us that managers are auditing dependency & staff numbers are changed to reflect this as required. Staff told us that they had received a good induction and training records confirmed that staff training was maintained to ensure that staff had received training in mandatory areas including abuse awareness and further training in care planning and record keeping. When staff have started to work having received a POVA check but not yet received a CRB check, the management are recommended to ensure that a record of how they are supervised is maintained to ensure that there is no risk to people using the service. People using the service were complimentary about the staff describing them as Kind and helpful and they said they felt well cared for. Recruitment procedures were examined and were in place to ensure that people using the service were not placed at risk. The Management of the home is recommended to ensure that clear employment history is obtained from prospective staff to ensure that people using the service are not placed at risk and that records of interviews are maintained to provide a clear audit of decision making. Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 22 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): 33 35 36 37 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed to promote peoples independence and promote peoples health and safety. The management of people using the service monies is and well managed and all records are maintained in line with the Data Protection Act. Staff supervision is recommended to be undertaken regularly and to include all aspects detailed in the National minimum standards. EVIDENCE: The home does not currently have a registered manager and recruitment continues. The home has a Manager Designate in post. The management of the home have been proactive in providing sufficient management cover over this extended period. Standards 31 and 32 have not been assessed. Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 23 Surveys asked staff if their manager gives support and discusses how they are working. 3 said sometimes. One staff member said that when meetings are held and things are asked for the staff do not always get them. One staff member explained that the people residing in the barns sometimes call in the night and some staff do not feel safe to go out in the night. This has been raised with the management but no action taken. One person commented that ‘It would be better to keep a manager for more than a couple of months’. No questionnaires had been sent out since the last key inspection. This is recommended to ensure a clear audit of peoples views on the home. The home has now implemented monthly regulation 26 reports undertaken by the provider and his representative. This monitors the care provided and demonstrate the development of the service to meet peoples needs. The provider also provides CSCI with a copy of the monthly report Personal monies can be stored by the home and a record maintained of all deposits and withdrawals. These records were noted to be correct and clear audit systems are now in place. Records stored at the home are stored securely and in line with the Data Protection Act. Staff are aware of the need for security of confidential documentation and all records are maintained individually. Supervision of staff was noted to have taken place but the content is limited to identification of training needs and achievements and appears to be task led. The regularity of supervision is also variable. The management of the home is recommended to develop supervision to include the areas identified in the National Minimum Standards and ensure that all staff receive supervision no less than 6 times per year. The records relating to health and safety were seen, these were mostly up to date. The hot water temperature checks were unclear but have subsequently been clarified and copies forwarded to CSCI. Accident records are available for people using the service and staff. There was no evidence that accidents have been audited and a response to that audit implemented. This is recommended to promote accident prevention. Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 24 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 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x 3 3 3 3 Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 25 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 OP7 Good Practice Recommendations The registered provider is recommended to further develop care plans to include all aspects of identified need. This is with reference to people who have challenging behaviour and specific care interventions. The registered provider is recommended to ensure that staffing levels are consistent to the calculated dependency levels. The registered provider is recommended to ensure that all prospective employees provide a detailed employment history, which includes dates of previous employment. This is recommended to ensure that there is no risk to people using the service. The registered provider is recommended to ensure that a record of interviews is maintained to provide a clear recruitment audit. The registered provider is recommended to ensure that a record is maintained of how staff are supervised when DS0000016043.V373402.R01.S.doc Version 5.2 Page 26 2. 3. OP27 OP29 4. 5. OP29 OP29 Netherclay House 6. OP33 7. OP38 awaiting the receipt of a CRB check. The registered provider is recommended to ensure that quality assurance monitoring is provided to include the surveyed opinions of all people who use the service. This is to ensure that the service is monitored and developed to meet the needs of people using the service. The registered provider is recommended to ensure that all accidents are recorded. Accident audits are recommended to be further developed to identify trends and repeated incidences to promote accident prevention. Previous recommendation not met The registered provider must ensure that staff receive supervision no less than 6 times per year and that the topics discussed are in line with the National Minimum Standards. His is required to monitor and promote good practice. 8. OP36 Netherclay House DS0000016043.V373402.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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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