Care Home: Newhey Manor, Residential Care Home

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What the care home does well What has improved since the last inspection? An administrator has been employed to assist with clerical tasks and also to help plan and deliver social activities in the home. This has given the manager and management team more time to concentrate on management issues and to further develop the service. The upstairs bathroom has been completely refurbished to include a high/low rise bath, walk in shower and an electronically programmed toilet, which will assist those residents requiring a little more support with their personal care. The manager actively listens to people who use the service and has improved the pre-admission assessment documentation to take into account the equality and diversity needs of each person. * * * The complaints procedure is now also supplied in large print making it easier for some people to read. The introduction of a post wallet in each bedroom. Post is placed in this for the resident and/or their relative to open in private. Residents are now actively encouraged to be involved in their own care planning. What the care home could do better: Only one requirement has been made at this inspection. Good practice could be improved in the following areas: making sure that balances of medication to be administered `as and when required` can easily be accounted for; where it is necessary to hand write medication administration records two members of staff should complete this task and sign in order to minimise the risk of errors occurring in the recording of information. Staff should not be expected to work excessively long shifts. CARE HOMES FOR OLDER PEOPLE Newhey Manor, Residential Care Home Newhey Manor Huddersfield Road Newhey Rochdale Lancashire OL16 3RL Lead Inspector John Oliver Unannounced Inspection 10th September 2008 07:15 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 Newhey Manor, Residential Care Home DS0000043980.V367322.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. Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Newhey Manor, Residential Care Home Address Newhey Manor Huddersfield Road Newhey Rochdale Lancashire OL16 3RL 01706 291860 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) info@lilycare.com Lily Care Limited Dr Rida Youssef Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 24 Date of last inspection 12th September 2006 Brief Description of the Service: Newhey Manor is a purpose built residential care home situated in Newhey, accommodating 24 service users over the age of 65 years. All the rooms are single, two having en-suite toilets. Permanent and respite stays are provided. Local shops are situated approximately half a mile away and the home is well served by public transport. Level access is provided to the main entrance. Car parking spaces are available to the front and side of the home. There are no private garden areas but service users may access the rear of the building, through patio doors, which open onto large playing fields. The home is well maintained both internally and externally. The weekly fees ranged from £352.00 £385.00 and additional charges were made for private chiropody, hairdressing and bingo. The provider made information about the service available upon request in the form of a Service User Guide and Statement of Purpose, which was given to new residents. A copy of the most recent Commission for Social Care (CSCI) inspection report was displayed in the entrance hall. Newhey Manor, Residential Care Home DS0000043980.V367322.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 3 stars. This means the people who use this service experience excellent quality outcomes. The inspection was undertaken as part of a key inspection, which includes an analysis of any information received by us (the Commission for Social Care Inspection) in relation to the home prior to the site visit. This visit, which the home did not know was going to happen, took place over the course of 9 hours on Wednesday 10 September 2008. During the course of the site visit we spent time talking with the residents, the registered manager (owner) and staff on duty to find out their view of the home. Before the site visit we sent the manager of the home an Annual Quality Assurance Assessment (AQAA) document for them to complete and return to us with information about the service they provide. In this document the manager has the opportunity to tell us what they felt they did well, and what they needed to do better. We also received a number of surveys returned to us by staff working in the home. In these surveys we asked the staff to comment about their experiences of the home and some of the information shared with us has been used in this report. We also spent time examining various files and written information and spent some time looking around the building. A random inspection was also carried out in April 2007 to look at an anonymous complaint that had been raised and information about how this was dealt with has also been taken into account. What the service does well: The atmosphere in the home was warm, welcoming and friendly. People living in the home said that they enjoyed living there and that they were well looked after and staff were very good. Comments included, “When I’m not well they will send for my doctor and the district nurse comes to check my foot” and “Staff here are OK, they look after us all well”. Watching staff throughout the inspection indicated that they cared for the residents in a kind, caring and considerate way, respecting their views and wishes at all times. Meal times are seen as an important part of the day and residents and relatives spoken to were all extremely pleased with the meals served in the home. Comments included, “The menu is terrific – plenty of choice – mum loves the food here”, “We get good”, “Very good food – plenty of choice” and Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 6 “Excellent food – can’t get better”. The chef has worked in Newhey Manor for a number of years and knows the resident’s well and is able to ensure individual preferred choices, like and dislikes are respected and maintained. The manager regularly monitors care practice and record keeping in the home to make sure a good and appropriate level of records are kept and that the care being delivered meets the identified needs of the people living in Newhey Manor. The home was clean, hygienic and maintained to a good standard throughout. What has improved since the last inspection? What they could do better: Only one requirement has been made at this inspection. Good practice could be improved in the following areas: making sure that balances of medication to be administered ‘as and when required’ can easily be accounted for; where it is necessary to hand write medication administration records two members of staff should complete this task and sign in order to minimise the risk of errors occurring in the recording of information. Staff should not be expected to work excessively long shifts. Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 7 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. Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The admission process was comprehensive with relevant information being given to prospective residents before they moved in and a full and detailed assessment taking place to ensure the home can meet their identified needs. EVIDENCE: The statement of purpose and service user guide had been updated and was displayed within the home. Each new resident is provided with their own copy of both documents in accordance with the admission policy and procedure for Newhey Manor. The manager told us that all prospective resident’s received a full preadmission assessment before moving into the home. In most instances, the manager himself carries out these assessments, if not, a senior member of the management team will do this. Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 10 We looked at three files and saw that each contained a full and comprehensive assessment completed by the manager before the resident moved into the home. Where care managers (social services) were involved in supporting the admission, they had provided detailed needs assessments also. Residents and relatives spoken to confirmed that they were fully involved in the assessment process and one resident told us “I made the decision to live here – no one else did this for me”. During our visit we had the opportunity to speak with one visiting relative who told us “I’ve been kept aware of… needs all along the line – from day one”. On visiting a prospective resident for the first time, the person carrying out the assessment also provides initial information about the home in the form of a booklet called “Information for Prospective Users”. This information includes some quotes from people currently living in the home and gives a brief overview about Newhey Manor and the service provided. Admissions into the home are well planned and on the day we visited we observed a resident being discharged and one being admitted into the home and both were handled with sensitivity and courtesy by the staff on duty. The manager confirmed that the home did not offer intermediate care services. Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs were being well met and personal care and support was offered in such a way as to promote and protect residents’ privacy, dignity and independence. EVIDENCE: We looked at the files of three residents, one of whom had recently been admitted into Newhey Manor. Each contained an individual care plan and details in these gave staff all the information they needed in order to provide the right care and support to each person. Details within the care plan covered all aspects of needs and linked directly to any identified risk for the individual. These plans were reviewed and updated on a monthly basis with detailed information being recorded where changes were identified. One relative who spoke with us stated, “I am aware my mum has a care plan and the manager holds a review with us every six months”. Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 12 On resident who had recently suffered a broken hip due to a fall was being encouraged to mobilise by staff and was back walking within a month of leaving hospital. We spoke to the relative of this resident who was extremely pleased with the care provided and the way in which their relatives mobility and independence was continually being encouraged by the staff team. We also saw that records relating to personal hygiene and weight monitoring were in place and were up to date. Where sudden weight loss occurred we saw that the management team had taken appropriate action and contacted the relevant health care professionals to ensure any action needed could be taken sooner rather than later. One resident spoken to told us that they could have a bath whenever they wanted, “within reason”. As part of the monthly review of care plans, staff monitor and record the condition of residents’ skin and any concerns would be noted with appropriate action being taken. As part of this good practice, the manager also checks these records to make sure staff are carrying out any action required and that any concerns had been addressed. During our visit a number of health care professionals called at the home to see individual residents and to provide treatments. Staff treated these visiting professionals with respect and ensured that they made themselves available to assist them where needed. Records of such visits were recorded on the individual resident’s file and one resident told us “When I’m not well they will send for my doctor and the district nurse comes to check my foot” and another resident told us that he received pain relief when he needed it. The manager closely monitors falls, and if any resident has more than 3 falls within a sixmonth period a referral is made to the falls co-ordinator at Rochdale Infirmary and we saw that care plans had been updated accordingly. As part of the quality monitoring of the service provided by the home the manager sends all visiting health care professionals a survey questionnaire. This questionnaire asks specific questions about the service and those we examined that had been returned by doctors and district nurses clearly demonstrated that they considered a very good service was being provided to people living in the home. Those files we saw all contained completed assessments relating to moving and handling, falls and skin tegrity. Where any other risks had been identified, assessments had taken place and were on file, for example for the use of safety rails on beds. Where it was identified there was a high risk, a detailed action plan had been developed that showed how the risk was to be best managed in order to minimise it. Those residents we spoke to during this visit all said that the staff team was caring for them and that the home was well managed. Feedback from visiting relatives also indicated that they were very satisfied with the overall care being provided by the home and comments Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 13 included “(I am) very happy with the care provided” and “This is one of the better care homes – definitely”. Medication was administered in the home via a monitored dosage system and those staff with the responsibility for administering medication had all received appropriate training with the manager carrying out regular competency assessments to ensure good practice is maintained. Each resident has an individual Medication Administration Record (MAR) and individual photographs to aid identification. From observing the lunch-time medication round, the carer was seen to administer the medication efficiently, signing the MAR only after making sure each resident had swallowed their tablets. One resident told us “I get it (medication) when I should – it never runs out”. We checked a number of medications that were to be administered ‘as and when required’ and found that balances of this type of medication were difficult to check as balances left from the previous month had not been carried forward onto the current months record. It is important that all medication can be accounted for at any time and that records reflect this. A number of handwritten entries had been made on the MAR’s and where this needs to be done two staff should sign to verify the entry made is correct and in accordance with the prescribed directions. The manager confirmed that 3 residents manage their own creams and inhalers and this is monitored with risk assessments in place. Three residents were being administered Controlled Drugs and the balances and records for this medication was checked and found to be correct. The current cabinet in which this medication is stored no longer complies with new legislation and must be replaced. We watched how the staff and manager interacted with residents and we observed that care practice such as assisting a person to the toilet or bathrooms was done discreetly and without people having to wait. Toilet doors were closed whilst in use and staff knocked on doors before entering. Those residents spoken to during this visit were all very complimentary about how staff assisted them with personal care tasks and felt their privacy and dignity was respected at all times. Relatives spoken to said they were very satisfied with the staff’s attitude and how they assisted people living in the home and comments included, “You can’t complain about a thing to do with staff – they really do care”. Newhey Manor, Residential Care Home DS0000043980.V367322.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Daily routines in the home demonstrated that residents were encouraged to maintain control over their lives, were encouraged to maintain contact with the community and are provided with a wholesome and well balanced diet. EVIDENCE: When we arrived at the home at 7:15 am three residents were already up and in the lounge area. When asked, all confirmed they had chosen to get up early and that staff had assisted them to get dressed at their request. Part of the individual care plan for each resident is now a section called ‘A day in the life of’. In this section staff record preferred routines, likes and dislikes of each resident and this information is then used to make sure peoples preferred choices and routines are respected and offered whenever possible. Whilst looking around the home we saw that each bedroom had a “Do not disturb” sign that could be hung on the outside handle of the door and when asked, staff confirmed that these were regularly used by a number of residents who liked to stay in bed ‘for a bit longer’. Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 15 Since the last key inspection visit in September 2006 further improvements have been made in the way in which activities are offered and delivered in the home. People get offered the choice to participate in activities they may want to be involved in and no one is forced to participate or be involved against their wishes. From speaking with residents and the information recorded in the activities register, it was evident that the needs of both individuals and groups were being addressed. Various in-house activities take place, including fortnightly visits from an outside entertainer “Active Minds” and other random activities such as arts/crafts, quizzes, reminiscence and member games. A number of residents had decorated their rooms with artwork they had produced at activity sessions and others with photographs of events they have been involved in. Seasonal themed parties take place throughout the year and residents have access to a payphone or a mobile telephone should they wish to contact friends or family and a number of residents also have a private telephone line to their room. The local Ring and Ride service is used by a number of residents to access the local community. Activities are arranged for the summer months and in August a barbeque was held for the residents and their relatives and photographs displayed in the home demonstrated that all involved enjoys such events. Residents have opportunities to observe their religious beliefs and representatives from both Church of England and Roman Catholic faiths regularly attend the home to provide church services. Residents and relatives spoken to told us that visitors were always made welcome in the home and were always offered refreshments. The chef has worked at Newhey Manor for a number of years, is qualified and very experienced in providing nutritionally appropriate food that meets the likes/dislikes of the people living in the home. Menus are planned over a 4 – week period and offer two hot choices of meal at lunchtime and a choice of sandwiches or a hot snack at tea. Desserts are offered and served after both meals. Residents, relatives and staff spoken to were extremely complimentary about the meals provided and comments included, “The menu is terrific – plenty of choice – mum loves the food here”, “We get good food”, “Very good food – plenty of choice” and “Excellent food – can’t get better”. On the day of this visit the lunch choices were, chicken enchilada, salad and garlic bread or roast chicken, carrots, cabbage, roast and mashed potatoes and gravy. The dessert was spice sponge and white sauce or jelly and cream. The tea choice was bacon and cauliflower cheese or corned beef and onion sandwiches followed by mandarins and orange jelly or ice cream. The individual dietary needs of residents were being met and dietary and fluid charts were being completed as and when required. All residents had been Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 16 assessed using the Malnutrition Universal Screening Tool (MUST) and appropriate action had been taken where identified as necessary such as the provision of additional nutritional supplements. Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 17 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies, procedures and training measures were in place for staff to support residents to raise any issues of concern and to protect residents from neglect and abuse. EVIDENCE: On entering Newhey Manor a copy of the complaints procedure can be found on the desk in the hallway and a copy is also included in the service user guide and statement of purpose. Details in the complaints procedure are clear and include timescales for responses and relevant information about other agencies that could be contacted such as the Commission for Social Care Inspection if required. The manager of the home maintains a complaints record and we saw that one complaint had been received in the last 12 months. This complaint was from a resident in the home and details within the record indicated that the complaint had been concluded to the satisfaction of the complainant. The Commission for Social Care Inspection had received no complaints about the service in the last 12 months. A comments book was displayed in the hallway and we saw that many thank you cards had been received. The residents and relatives we spoke to during our visit to Newhey Manor all said that they felt they could speak to the Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 18 manager or any of the staff about any concerns or worries they may have and that they would be listened to. One relative said, “The manager is always ready to listen – any minor concerns are dealt with straight away”. The home has a policy and procedure for responding to allegations of abuse that includes the Rochdale Inter-Agency Protection of Vulnerable Adults (POVA) procedure. The manager told us that no protection investigations had taken place in the last 12 months and since the last key inspection most staff have attended the Rochdale MBC POVA training course. Those staff that have completed National Vocational Qualification (NVQ) training level 2 also completed a training unit on elderly abuse. We spoke to a number of staff during our visit to the home and all were very clear about the process to follow should an allegation of abuse be made. The manager was also able to demonstrate a good understanding of the role he must undertake in the event of any allegation being made. The manager confirmed that a Criminal Record Bureau (CRB) enhance disclosure and POVA First checks had been done before any new staff started work so as to ensure that the staff were suitable to work with vulnerable people. Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 19 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean, safe and well maintained and provided a comfortable and homely environment for the residents. EVIDENCE: The home was well maintained and when bedrooms became vacant, they were re-decorated before a new resident was admitted. The manager told us within the Annual Quality Assurance Assessment (AQAA) that he completed and returned to us before this visit took place, that all corridors, staircase, office and four bedrooms have been re-decorated. As we looked around the building we saw that bedrooms had been personalised by residents to reflect their individual character and many contained artworks that had been completed by the resident during activity Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 20 sessions. A number of residents spoken to told us that they were very satisfied with their bedrooms and said the home was always kept clean and tidy. One resident told us, “I love my bedroom – it overlooks the field – it is always kept spotlessly clean” and another resident said, “We have a good cleaner – she does all around the home everyday”. We saw that appropriate aids and adaptations were fitted in bathrooms and toilets so that residents could remain as independent as possible. Since the last key inspection visit one upstairs bathroom has been completely refurbished to include an assisted high/low bath, walk in shower and a toilet with a wash/dry electronic programme to enhance the personal care for those residents who may need a higher degree of support. Equipment such as disposable gloves and coloured aprons were provided around the home for staff to use and liquid soap and paper towels were supplied in all bathrooms and toilets. In addition, alcohol based hand wash dispensers were provided on both floors of the home which staff regularly use. There was an infection control policy in place and most staff had completed training in this subject and staff interviewed described safe infection control practice. The laundry was sited away from the food preparation area and was found to be well organized and sufficient and suitable equipment was provided, including washers with sluicing facilities. Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 21 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of staff are employed in the home and a robust recruitment and selection process is in place that helps protect residents EVIDENCE: We looked at the copy of the latest staffing rota and this showed us that staffing levels appeared to be adequate to meet the needs of the resident’s currently living in Newhey Manor. Those staff we spoke to and those that returned survey questionnaires to us before the visit took place said that staffing levels in the home were, in the main, adequate to meet the needs of the residents. On the day of our visit there was at least one member of staff working a double shift i.e. 8.00 – 15.00 and 15.00 – 22.00. This length of shift pattern is excessively long and staff cannot be expected to perform efficiently and effectively when working such long hours. The manager told us that he was in the process of recruiting more staff and this will reduce the need for existing staff to work double shifts when other staff ring in sick or take annual holiday’s. Since the last key inspection visit a number of new people have been employed in the home and we looked at the files of four of these staff. These records Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 22 demonstrated that appropriate pre-employment checks had been carried out prior to the person starting work in the home and one of the newly recruited care assistants confirmed she had not started work until all her checks had been received by the home. Speaking to both residents and relatives during our visit gave a clear indication that good and positive relationships had been developed between staff and residents and we saw that staff maintained respect when assisting residents with their day-to-day needs. Skills for Care induction training was taking place for all new staff and from checking the staff training matrix it was seen that staff were booked on various training courses throughout the year. Ten members of the staff team including the manager had recently completed a training course on Privacy, Dignity and Equality and Diversity and speaking to staff confirmed that regular training was taking place and comments included, “We get training – more training than ever before” and “Six of us completed medication training with Boots yesterday”. We also saw copies of training certificates kept on a separate file. The manager confirmed within the Annual Quality Assurance Assessment (AQAA) returned to us before this visit took place, that nine care staff have successfully obtained a National Vocation Qualification (NVQ) at level 2 or above which is more that 50 of the workforce. Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 23 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 and 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 well managed for residents and care staff are appropriately supervised. The health and safety of residents and staff is, in the main, safeguarded. EVIDENCE: Speaking with the manager demonstrated that he considered training as an essential part of the staffs team development and he closely monitored care practices within the home, which also involved carrying out regular audits and spot checks of things such as care plans and the way in which staff responded to residents needs on a day to day basis. Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 24 We spoke to residents, relatives and staff about the manager and the feedback we received was very positive and supportive. Staff confirmed that they received regular one to one supervision sessions and participated in regular staff meetings where the manager encouraged them to be open and honest with their opinions in order that the service can continue to positively develop. One relative spoken to also confirmed that the manager always listened to what he had to say and knew that his opinions were valued and respected. The home hold the Investors in People Award and an annual quality assurance survey is carried out involving residents, relatives, friends and staff. Since the last key inspection in September 2006 this survey has been further expanded to include the views and opinions of visiting healthcare professionals such as General Practitioner’s, District Nurses and Care Managers. The evidence for the survey was obtained through the circulation of questionnaires from which the manager uses the information shared to develop an action plan for the next 12 months. The results are published and displayed within the home and are then included in the service user guide. We saw minutes from the meetings held with residents and their relatives, the last one being held on 17 August 2008 and one relative confirmed that he had attended this meeting which had been very positive and that a decision had been made to form a committee in order to further support the management of the home. Staff and management meetings were taking place regularly and we saw copies of the minutes from these meetings. The manager regularly reviews the policies and procedures for the home and has continued to address any recommendations made by the Commission for Social Care Inspection in the last inspection report. The majority of the residents living in Newhey Manor relied upon their relatives to handle their financial affairs. The home were only managing the personal allowance for one person and appropriate receipts were seen to have been signed by the resident upon receipt of their personal allowance money. Some relatives occasionally leave money at the home for staff to give to an individual resident as they needed it and again, receipts were in place where staff had purchased items of their behalf. The manager told us that the maintenance and servicing of equipment used in the home had been carried out and a random selection taken from the service records during our visit confirmed this. Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 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 Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? 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 OP9 Regulation 13 (2) Requirement To make sure Controlled Drugs are appropriately stored, storage facilities must be provided that are compliant with current legislation. Timescale for action 31/12/08 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 OP9 Good Practice Recommendations a) Records should be maintained of balances of medication that is administered ‘as and when required’. b) Where it is necessary to hand write medication administration records it would be good practice for two members of staff to complete this task and sign in order to minimise the risk of errors occurring in the recording of the details. It would good practice for staff not to work excessive hours. 2 OP27 Newhey Manor, Residential Care Home DS0000043980.V367322.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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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