Care Home: Northbourne

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What the care home does well What has improved since the last inspection? Following a random inspection visit to the home, staffing levels have been increased to take account of people`s assessed needs and dependency levels. Improvements have been made to the home`s external areas. An enclosed patio area has been built and additional car parking spaces have been provided. Notice boards have been put up in the main reception area as suggested by the `Friends of Northbourne` group. An activities co-ordinator has been appointed to ensure that people are provided with access to a good social programme. New care documentation has been introduced. The care plan format has been adapted to include a section on equality and diversity. A pre-admission assessment has been added to the documentation. All staff have completed dementia and safeguarding training. Six staff have completed a five day dementia training course. Additional staff have been appointed including an administrator and a handy person. All staff have received training in medication in line with the provider`s national contract. Staff have also received training in the new assessment and care planning processes. A new audit system has been introduced to ensure that medication is well managed within the home. A daily food platter has been introduced. A care specialist has been appointed to review adult protection issues within the Trust and to ensure that any lessons learnt are shared with staff. New IT systems have been introduced to ensure that the Trust functions more effectively. The home`s brochure, statement of purpose and service user guide have been revised since the last inspection. What the care home could do better: Ensure that staff receive supervision at least six times a year. This will help to ensure that people working at the home are appropriately supervised and are providing care that delivers good outcomes for people using the service. CARE HOMES FOR OLDER PEOPLE Northbourne Durham Road Low Fell Gateshead Tyne & Wear NE9 5AR Lead Inspector Glynis Gaffney Key Unannounced Inspection 16 and 27 October 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Northbourne DS0000007401.V372789.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. Northbourne DS0000007401.V372789.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Northbourne Address Durham Road Low Fell Gateshead Tyne & Wear NE9 5AR 0191 482 5859 0191 482 4513 alison.fryer@anchor.org.uk keri.sherwood@anchor.org.uk Anchor Trust 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) Miss Alison Fryer Care Home 33 Category(ies) of Dementia - over 65 years of age (8), Mental registration, with number disorder, excluding learning disability or of places dementia (2), Mental Disorder, excluding learning disability or dementia - over 65 years of age (9), Old age, not falling within any other category (36), Physical disability over 65 years of age (13), Sensory impairment (2), Sensory Impairment over 65 years of age (2) Northbourne DS0000007401.V372789.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th July 2008 Brief Description of the Service: Northbourne is a registered care home providing personal care for up to thirtythree older people, some of whom have mental health needs, a physical disability or sensory impairment. The home does not provide nursing care. The home has three floors. The ground floor accommodates the kitchen, laundry, the manager’s office and staff room. On the ground and first floors there are a variety of communal areas, the care staff office and individual flats, all of which have en-suite facilities. There is a passenger lift to all floors and a call system is installed in all areas accessed by people using the service. Northbourne is a purpose built home owned by Anchor Trust and is located on Durham Road in Low Fell Gateshead. It is close to shops, a medical centre, bus routes and other local amenities. There are pleasant garden areas and car parking facilities to the front of the building. A copy of the home’s last inspection report is available in the reception area. Fees for this service are between £359 and £386 per person per week. Northbourne DS0000007401.V372789.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 star. This means the people who use this service experience good quality outcomes. We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. How the inspection was carried out: Before the visit: We looked at: • • • • • Information we have received since the last key inspection visit on the 21 December 2005; How the service dealt with any complaints and concerns since the last visit; Any changes to how the home is run; The manager’s view of how well they care for people. We also interviewed three people who use the service and three staff; The views of relatives, other professionals and staff. The Visit: An unannounced visit was made on the 16 October 2008. inspection we: • • • • • • During the Talked with some of the staff on duty; Looked at information about the people who use the service and how well their needs are met; Looked at other records which must be kept; Checked that staff have the knowledge, skills and training to meet the needs of the people they care for; Looked around the building to make sure it was clean, safe and comfortable; Checked what improvements have been made since the last visit. Northbourne DS0000007401.V372789.R01.S.doc Version 5.2 Page 6 What the service does well: The needs of people wishing to use the service are fully assessed so that the provider can ensure that they are able to meet identified needs. Once people have moved into Northbourne, a comprehensive assessment of their needs is carried out. Staff training on specific areas of health care takes place according to people’s needs. The home is generally well maintained. On the day of the inspection, Northbourne was clean, tidy, hygienic and safe. People are provided with ensuite flats that have their own letterbox. People are provided with a key to their flat so they can control whose goes in and out. All staff receive health and safety training and the home is audited to a ‘safe site standard’ by Anchor’s support services. Staff have developed caring relationships with the people they look after and are respectful, considerate, understanding and patient. Staff are enthusiastic and positive about their work. The ‘Friends of Northbourne’ group meets regularly and promotes the wishes of people using the service. There is a room available for families to stay overnight if needed. The team at Northbourne includes staff that have completed assessor and verifier training. This enables the home to provide a better and more responsive staff training programme. The home’s senior team have obtained relevant qualifications in social care. Staff who returned surveys said: • • • • People are given choices; We provide care with the emphasis on the individual. We provide good ‘end of life’ care. Families often ask if their relative can stay with us rather than be moved elsewhere; The home provides a safe and caring environment for the residents. We care about them as individuals; The training is very good. There are regular staff meetings and supervision. Relatives who returned surveys said: Northbourne DS0000007401.V372789.R01.S.doc Version 5.2 Page 7 • • • • • Everyone is excellent when someone is ill and staff genuinely care for people. The food is very good and the home is always clean. Staff have caring relationships with the people they care for; The home provides a 24 hour service that revolves around the needs not only of my mother but the other residents too; Staff are provided with good training opportunities; Communication with families is good; Staff are pleasant and welcoming. What has improved since the last inspection? Following a random inspection visit to the home, staffing levels have been increased to take account of people’s assessed needs and dependency levels. Improvements have been made to the home’s external areas. An enclosed patio area has been built and additional car parking spaces have been provided. Notice boards have been put up in the main reception area as suggested by the ‘Friends of Northbourne’ group. An activities co-ordinator has been appointed to ensure that people are provided with access to a good social programme. New care documentation has been introduced. The care plan format has been adapted to include a section on equality and diversity. A pre-admission assessment has been added to the documentation. All staff have completed dementia and safeguarding training. Six staff have completed a five day dementia training course. Additional staff have been appointed including an administrator and a handy person. All staff have received training in medication in line with the provider’s national contract. Staff have also received training in the new assessment and care planning processes. A new audit system has been introduced to ensure that medication is well managed within the home. A daily food platter has been introduced. A care specialist has been appointed to review adult protection issues within the Trust and to ensure that any lessons learnt are shared with staff. Northbourne DS0000007401.V372789.R01.S.doc Version 5.2 Page 8 New IT systems have been introduced to ensure that the Trust functions more effectively. The home’s brochure, statement of purpose and service user guide have been revised since the last inspection. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Northbourne DS0000007401.V372789.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 Northbourne DS0000007401.V372789.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): 3. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are suitable arrangements for making sure that people’s needs are assessed before they are admitted into the service. This helps to ensure that staff will be able to meet people’s needs on admission. EVIDENCE: Admissions do not take place until a full needs assessment has been carried out by qualified and experienced staff. Where social services have carried out the assessment, the service ensures that it receives a summary of each person’s assessment. Any assessment information received is placed in people’s care records. The majority of staff said they receive enough Northbourne DS0000007401.V372789.R01.S.doc Version 5.2 Page 11 information to enable them to meet people’s needs on admission into Northbourne. This means that people can be confident that the home will look after them appropriately and meet all their assessed needs. Northbourne DS0000007401.V372789.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are satisfactory arrangements for ensuring that people’s physical and health care needs are met. This means that people can be confident that staff will be able to meet their assessed needs. EVIDENCE: The records of three people were looked at. This showed that: • Care plans have been devised for each person. These provide staff with information and guidance about how to meet people’s needs. Care plans address people’s needs in a range of areas such as mobility, nutrition and personal care. However, some people’s care plans have not been reviewed on a monthly basis and some did not cover all of the areas referred to in the National Minimum Standards; The home obtains information about people’s likes and dislikes and preferred daily routines. Staff have completed social histories for each DS0000007401.V372789.R01.S.doc Version 5.2 Page 13 • Northbourne person. This will help staff to more fully appreciate the life experiences of each person before they moved into the home. People using the service who returned surveys said that they are very happy with the care they receive and feel well looked after. The majority of relatives also confirmed this. On the day of the inspection, people looked well cared for and staff responded to people’s needs promptly and in a caring manner. People’s care records contain information that demonstrates that staff take action to meet their health care needs. For example, staff had arranged for one person to see their GP on eight occasions since their admission in May 2008. For another person admitted in March 2008, a hearing health care check had been arranged. This person had also been seen by a community nurse on three occasions and had had their medication reviewed by their GP. Another person had seen an optician, chiropodist and dentist during the previous seven months. People said that they felt confident that staff would be able to meet their health care needs. Preventative health care risk assessments are carried out. For example, in the three sets of care records checked, nutritional, skin care and falls prevention risk assessments had been carried out for each person. However it was identified that the Body Mass Index section of the nutritional risk assessment had not been completed. Failure to fully complete nutritional assessments could lead to gaps in staff’s knowledge about how to keep people healthy. Some risk assessments had not been signed or dated, and some had not been reviewed on a regular basis. Ms Fryer said that wherever possible, people and their families are involved in the preparation of care plans and their views taken account of. This helps to ensure that people are involved in and are aware of, any decisions taken about their care. The home has a safe and effective policy in place for the administration and storage of medicines. A pre dispensed monitored dosage system is used that minimises risk so that people are protected. A sample of medication records was checked. This showed that medication records are generally well maintained. However, there was no evidence in one person’s care records that a medical opinion had been sought about their regular refusal of essential medication. There has been one incident involving the mis-administration of medication since the last inspection. The provider carried out an investigation and action was taken to prevent a further re-occurrence. Regular audits of the home’s medication practices and procedures are carried out and where issues are identified these are shared with staff to improve practice. The medication trolley and treatment room are kept in a clean and hygienic condition. Staff support people to make choices and decisions about their daily life at Northbourne. For example: Northbourne DS0000007401.V372789.R01.S.doc Version 5.2 Page 14 • • Staff consult people about their meal choices on a daily basis. People said that staff always ask them about what they want to eat and drink; People are supported to look after their personal appearance and personal support is provided in private. Staff encourage visiting health care professionals to see people in the privacy of their own bedrooms. The majority of family relatives who returned surveys said that they felt the service supports people to live the life they choose. However, one relative did comment that they felt residents are ‘expected to fit in with the pattern of life at the home’ and that they ‘do not have a lot of choice.’ Northbourne DS0000007401.V372789.R01.S.doc Version 5.2 Page 15 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. The arrangements for providing people with opportunities to participate in a range of stimulating social activities are generally satisfactory. This means that people are supported to live a more fulfilling lifestyle. EVIDENCE: The home obtains information about people’s social interests and hobbies before and after their admission into Northbourne. A social needs care plan is then devised for each person. However, some of those examined were limited and contained generic statements about how people’s social care needs will be met at the home. The home has recently employed an activities co-ordinator. This person is responsible for organising the provision of social events and activities within the home. There is a social activities programme, which is posted throughout the home. People said that they are invited to participate in activities but are Northbourne DS0000007401.V372789.R01.S.doc Version 5.2 Page 16 able to decline if they are not interested. The ‘Friends of Northbourne’ group contributes to the provision of activities within the home by making sure their ideas and wishes are taken into account when the programme is revised. People’s care records show that they are provided with access to a range of social activities. For example, in one week, a person had gone to the theatre, participated in a trip out to Gateshead and had attended an in-house entertainment event. They had also attended a ‘Friends of Northbourne’ meeting. Arrangements have been made for a local vicar to give Holy Communion each month. However, care plans have not been devised which set out how staff should meet people’s religious care needs. A hairdresser visits weekly. Visitors are made welcome and there are no restrictions on visiting times. In the communal lounges there are small kitchen areas that visitors can use to make hot drinks. People are able to request a key to their flat. This helps people to retain their privacy, maintain their independence and control who has access to their flat. The inspector joined people for their lunchtime meal. There was a friendly, unhurried atmosphere with people chatting to each other and with the staff. The tables were well presented with tablecloths, condiments, napkins and suitable cutlery. The meal served was tasty, nutritious and nicely presented with good portion sizes. Glide/slide chairs made sitting at and moving from the table easier for those who are mobile. Staff provided people with the support they needed to eat their meal. This was carried out in a dignified manner. People are asked the night before what they would like to choose from the menu for the next day. People confirmed that alternatives are always available and people can change their minds if they wish. Breakfast is from 9a.m. and people can choose whatever they want as both ‘cold’ and ‘hot’ food is available. Teatime is around 5pm and again people can choose from either a ‘cold’ or ‘hot’ menu choice. People said that the food served at the home is very good. Northbourne DS0000007401.V372789.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. A robust complaints procedure is in place that gives clear directions to people using the service and visitors so that they know how to complain and who to. Staff are trained in adult protection procedures to help them protect people from harm. EVIDENCE: The provider’s complaints procedure is displayed throughout the home so that people using the service, and their families, know who to complain to and how to make a complaint. The procedure is included in the service user guide a copy of which has been placed in each individual ‘flat.’ A complaints booklet is displayed in the main entrance. The manager keeps a register of any complaint received by the home. However, it is not always clear what the outcome of each complaint is. Staff who returned surveys said that they are clear about how to handle complaints. People using the service said that they would feel comfortable about making a complaint. They also said that they felt they would be listened to and taken seriously. Northbourne DS0000007401.V372789.R01.S.doc Version 5.2 Page 18 With the exception of new starters, training records demonstrate that all staff have attended safeguarding training. Talking to staff confirmed that they would know what to do if they suspected or witnessed abuse. This means that people can be confident that the staff group have the skills to protect them from abusive situations. The home has notified the Commission of two safeguarding concerns. In the first instance, the manager took immediate action to protect a person from financial abuse. The home ensured that all relevant professionals were informed of the concern that had been identified and worked in partnership with the local safeguarding team. The local authority is currently looking at the second safeguarding concern. Northbourne DS0000007401.V372789.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 standard of accommodation is satisfactory and meets the needs of those people who use the service. EVIDENCE: The communal areas and some people’s ‘flats’ were visited during the inspection. These areas were clean, warm, well furnished and decorated to a good standard. The ‘flats’ had been personalised by the occupants and people said that they had been encouraged to bring personal effects in with them. Northbourne DS0000007401.V372789.R01.S.doc Version 5.2 Page 20 Generally, the home is pleasantly decorated in calming and peaceful colours. All ‘flat’ doors have signage and a letterbox. People said that they are satisfied with their bedrooms. Lounges contain comfortable furniture and each has its own kitchen facility that staff and visitors can use to make beverages and simple snacks. Although the reception area carpet has recently been replaced, it is stained in places and there is an unsightly burn mark on the carpet near the entrance. Repairs and maintenance work are carried out by outside contractors. Records of maintenance carried out are clearly documented and are up to date. The laundry was clean and fit for purpose. No offensive odours were detected throughout the inspection. Northbourne DS0000007401.V372789.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. People can feel confident that their needs will be met by sufficient numbers of professionally qualified staff that are able to provide good quality care. EVIDENCE: A minimum of four staff are rostered on duty between 8am and 10pm. Extra staff are made available at busier times of the day. A senior member of staff is available on each shift. Members of the management team are also available on a daily basis. The rotas contain recommended details with the exception of staffs’ full names. In surveys returned to the Commission, staff said that there are only enough staff on duty ‘sometimes’. Following a random inspection conducted in July 2008, the Commission expressed concerns about inadequate staffing levels. The provider responded by increasing the numbers of staff on duty. Staff said that recent changes in people’s dependency levels have made current staffing levels more realistic. The inspector did not observe any instances where people’s needs went unmet. Staff files contain evidence that robust pre-employment checks are carried out. For example, staff files contain application forms, interview records, two Northbourne DS0000007401.V372789.R01.S.doc Version 5.2 Page 22 written references and confirmation of whether staff have any convictions or cautions. Staff’s identities have also been verified. This means that people can be confident that staff recruitment procedures safeguard them from harm. Each member of staff has a personal development file containing relevant information about their training and documentary evidence of training undertaken. There are opportunities for staff to complete training in health and safety, moving and handling, food hygiene, first aid and fire safety. Arrangements have been made for a new member of staff to complete training in all of the above areas. However, one member of staff had not updated their moving and handling training during the previous 12 months. Arrangements are in place to ensure that newly employed staff complete both an in-house as well as a ‘Skills for Care’ induction. This means that people can be confident that staff will know how to meet their assessed needs. Seventeen staff have obtained a National Vocational Qualification in care at Level 2 or above. This means that the service has exceeded the National Minimum Standard in this area and people can be confident that the staff that care for them are well trained. Generally, staff who returned surveys said that their employer had completed the required pre-employment checks; induction covered everything they needed to know to do their job; training was relevant to their role, helped them to understand the needs of the people they care for and kept them up to date with new ways of working. Staff also said that they felt that they had the right support, experience and knowledge to meet the different needs of the people using the service. Northbourne DS0000007401.V372789.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, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good management systems are in place and staff follow safe working practices. This means that people can be confident that they will be kept safe and protected from harm. EVIDENCE: The manager holds the Registered Manager’s Award and has substantial experience of meeting the needs of older people within a residential setting. Discussions with the manager confirmed that they regularly update their training to ensure that their practice is up to date. Staff said that the home is Northbourne DS0000007401.V372789.R01.S.doc Version 5.2 Page 24 well run, the manager is approachable and ensures that people’s needs are well met. Staff are not receiving formal supervision at the frequency stated in the National Minimum Standards, which states that each member of staff should receive formal supervision at least six times a year. For example, there was no evidence that one member of staff had received any formal supervision during the previous 12 months. Another member of staff had only received one supervision session in 2007. Of the seventeen staff that returned surveys, ten staff said that their manager met with them ‘regularly’ or ‘often’. Five staff said that this is ‘sometimes’ the case and two others said this ‘never’ happened. The manager completes a self-assessment manual that covers such areas as care practice, health and safety, administration, kitchen and medicines. The provider has devised a comprehensive checklist that enables senior staff to assess how well medicines are managed within the home. Following completion of the audit, an action plan is drawn up to address any shortfalls identified. The provider carries out regular monitoring checks to ensure that quality checks are being completed in line with the guidance contained in their self-assessment quality manual. However, the manager confirmed that the self-assessment manual had not been updated in 2007, but said that she was in the process of completing the revised quality assurance documentation recently issued to the home. People using the service and their families are encouraged to participate in ‘Friends of Northbourne’ meetings where views and opinions can be shared with the home’s management team. People’s money is kept secure at all times and clear records are kept. The manager carries out regular audits and further checks are completed by the provider during their monitoring visits to the home. A sample of financial records were checked and found to be satisfactory. People can be confident that their personal finances are well managed and their financial interests protected. Arrangements are in place to protect people from harm. For example, a personal emergency evacuation plan has been devised for each person. This will help to ensure that staff know how to safely evacuate people from the building if this is ever needed. An infection control audit took place in September 2008. This has helped the manager to reach a judgement that staff are following best practice guidance in the area of infection control. A tour of the premises revealed no health and safety concerns. Northbourne DS0000007401.V372789.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 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 2 X 3 Northbourne DS0000007401.V372789.R01.S.doc Version 5.2 Page 26 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 OP36 Regulation 18 Timescale for action Ensure that staff receive 01/04/09 supervision at least six times a year. This will help to ensure that people working at the home are appropriately supervised and are providing care that delivers good outcomes for people using the service. Requirement 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 Ensure that: People’s care plans are reviewed monthly and a written record kept; • People’s care plans cover all of the areas referred to in the National Minimum Standards; Care plans covering people’s religious care needs are Northbourne DS0000007401.V372789.R01.S.doc Version 5.2 Page 27 • 2. OP8 devised. Ensure that: People’s nutritional care risk assessments are fully completed; All healthcare risk assessments are signed, dated and reviewed on a regular basis. Ensure that a medical opinion is sought whenever people refuse essential medication on a prolonged and regular basis. A written record of the outcome should be kept. Ensure that each person’s social care plan reflects their individual interests and personal preferences. The plan should clearly state how the home intends to meet their individual needs. Ensure that the outcome of each complaint is fully recorded and a record kept at the home. Ensure that the home’s rotas include details of staff’s full names. • 3. 4. OP9 OP12 5. 6. OP16 OP27 Northbourne DS0000007401.V372789.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Northbourne DS0000007401.V372789.R01.S.doc Version 5.2 Page 29 - 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. 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