Care Home: Northwood

Similar services:

• Birchwood
• The Infirmary
• Orchard House Nursing Home
• St Josephs Rest Home
• Red Court Nursing Home
• Spinney (The)
• Queen Elizabeth House
• Henry Nihill House

What the care home does well Relatives and residents thought highly of staff and the feedback received from them was positive and indicated that they were satisfied with the care provided in the home. The arrangements for the provision of meals was of a high standard and residents were happy with the meals provided. The chef had worked for many years in the home and was aware of the dietary preferences of residents. We Northwood DS0000010507.V375685.R01.S.doc Version 5.2 were also informed by the manager that birthdays of residents are celebrated in the home. The premises were homely, clean and well decorated. Bedrooms felt cosy. The garden was attractive and colourful. The conservatory is an attractive feature of the home. Residents informed us that staff treated them with respect and dignity and their privacy was respected. There was regular interaction between staff and residents. The manager and staff interviewed were knowledgeable regarding the needs of residents. Staff informed us that there was good communication between staff and with the manager. They said there was a good team spirit and they got on well with each other. There was a low turnover of staff. The manager and her staff co-operated fully with us and information asked for was provided. What has improved since the last inspection? The kitchen had been refurbished. The chef stated that he was happy with the equipment available. There was evidence that staff had been provided with training in infection control. This is necessary for health and safety reasons. Effort had been made to improve the pre-admission assessments. The manager reassured us that she intended to improve the assessment forms to ensure that all relevant information was obtained prior to a service user coming to the home. What the care home could do better: The registered person must ensure that comprehensive pre-admission assessments are carried out before a prospective resident is admitted into the home. These assessments must include the cultural background, religious beliefs and pressure area condition of the prospective resident (in addition to assessments regarding the physical health, mental health, potential risks, social needs and financial situation). This is to ensure that the holistic needs of residents are attended to. The care plans of residents must be comprehensive. They must address the holistic needs of residents and include plans for meeting the physical, mental,NorthwoodDS0000010507.V375685.R01.S.doc Version 5.2 cultural, social and spiritual needs of residents. This is to ensure that the holistic needs of residents are attended to. A safety inspection of the chair lift must be carried out by a qualified professional. This is needed to ensure the safety of residents who use it. The home should have an administrator. This is to ensure that the manager is provided with administrative assistance. Residents meetings should be held at least once in two months and these should be recorded. During these meetings residents should be consulted regarding the activities provided. This is to ensure that residents are regularly consulted and informed of matters affecting the home and there is documented evidence of this. The home must have a Mental Capacity Act 2007 policy and procedure which includes guidance on The Deprivation of Liberty safeguards and a copy of the code of practice. This is required to provide guidance and safeguard the rights and best interests of residents. The large tree in the garden which appeared dead must be risk assessed in consultation with the appropriate professional and appropriate action taken to minimise any potential risk. This is for health and safety reasons. The fire risk assessment must be updated at least once a year. A minimum of four fire drills must be organised in a twelve month period. One of these must be carried out after dark. This is necessary to ensure the safety of residents and to ensure that staff are fully aware of action to be taken in the event of a fire. Key inspection report CARE HOMES FOR OLDER PEOPLE Northwood 24 Gloucester Road New Barnet Hertfordshire EN5 1RZ Lead Inspector Daniel Lim Unannounced Inspection 12th June 2009 09:00 DS0000010507.V375685.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Northwood DS0000010507.V375685.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Northwood DS0000010507.V375685.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Northwood Address 24 Gloucester Road New Barnet Hertfordshire EN5 1RZ 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) 020 8440 5853 F/P 020 8440 5853 Peter Michael Trainor Mrs Catherine Trainor Mrs Catherine Trainor Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Northwood DS0000010507.V375685.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specified service user who has dementia may remain accommodated in the home. The home must advise the regulating authority at such times as the specified service user vacates the home. 21st June 2007 Date of last inspection Brief Description of the Service: Northwood care home is registered to provide accommodation and personal care for a maximum of seventeen older people. The registered providers are Mr Peter Trainor and Mrs Catherine Trainor. Mrs Trainor is also the registered manager. The home is a two storey detached house. The office, laundry, kitchen, conservatory and lounge are located on the ground floor. Bedrooms are located on both floors There is one double bedroom on the ground floor, which is shared by two residents. All others are single bedrooms. There is a stair lift between the ground and first floors. There is a large garden at the back of the house. The front of the house has a small parking area. The home is located in a residential area of New Barnet and within a short walk of New Barnet train station, High Barnet underground station, local shops and bus services. The fees charged by the home may be obtained from the manager. The provider must make information about the service available (including reports) to service users and other stakeholders. Northwood DS0000010507.V375685.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 inspection was carried out by Daniel Lim, inspector on 12 June 2009 and took a total of seven hours to complete. We were assisted by the registered manager, Mrs Catherine Trainor. A second visit was made on 18 June 2009 to view documents and interview staff not present during the first visit. Four residents, a relative and a friend of a resident were interviewed. The impression gained was that they were well cared for. This was also confirmed in completed survey forms received from two residents, two relatives and a healthcare professional. Statutory records were examined. These included three residents’ case records, the maintenance records, accident and incident records, financial records, complaints records and fire records of the home. The premises including residents’ bedrooms, communal bathrooms, laundry, kitchen, garden and other communal areas were inspected. Four staff were interviewed regarding the care of residents and other areas associated with their work. They were noted to be knowledgeable regarding their roles and responsibilities. Staff records, including evidence of CRB disclosures, references, supervision and training records were examined. In addition, the minutes of residents’ and staff meetings were examined. These indicated that residents and staff had been informed of changes affecting the running of the home. The completed Annual Quality Assurance Assessment form or AQAA was previously received by CQC. Information provided in the assessment was used for this inspection. What the service does well: Relatives and residents thought highly of staff and the feedback received from them was positive and indicated that they were satisfied with the care provided in the home. The arrangements for the provision of meals was of a high standard and residents were happy with the meals provided. The chef had worked for many years in the home and was aware of the dietary preferences of residents. We Northwood DS0000010507.V375685.R01.S.doc Version 5.2 Page 6 were also informed by the manager that birthdays of residents are celebrated in the home. The premises were homely, clean and well decorated. Bedrooms felt cosy. The garden was attractive and colourful. The conservatory is an attractive feature of the home. Residents informed us that staff treated them with respect and dignity and their privacy was respected. There was regular interaction between staff and residents. The manager and staff interviewed were knowledgeable regarding the needs of residents. Staff informed us that there was good communication between staff and with the manager. They said there was a good team spirit and they got on well with each other. There was a low turnover of staff. The manager and her staff co-operated fully with us and information asked for was provided. What has improved since the last inspection? What they could do better: The registered person must ensure that comprehensive pre-admission assessments are carried out before a prospective resident is admitted into the home. These assessments must include the cultural background, religious beliefs and pressure area condition of the prospective resident (in addition to assessments regarding the physical health, mental health, potential risks, social needs and financial situation). This is to ensure that the holistic needs of residents are attended to. The care plans of residents must be comprehensive. They must address the holistic needs of residents and include plans for meeting the physical, mental, Northwood DS0000010507.V375685.R01.S.doc Version 5.2 Page 7 cultural, social and spiritual needs of residents. This is to ensure that the holistic needs of residents are attended to. A safety inspection of the chair lift must be carried out by a qualified professional. This is needed to ensure the safety of residents who use it. The home should have an administrator. This is to ensure that the manager is provided with administrative assistance. Residents meetings should be held at least once in two months and these should be recorded. During these meetings residents should be consulted regarding the activities provided. This is to ensure that residents are regularly consulted and informed of matters affecting the home and there is documented evidence of this. The home must have a Mental Capacity Act 2007 policy and procedure which includes guidance on The Deprivation of Liberty safeguards and a copy of the code of practice. This is required to provide guidance and safeguard the rights and best interests of residents. The large tree in the garden which appeared dead must be risk assessed in consultation with the appropriate professional and appropriate action taken to minimise any potential risk. This is for health and safety reasons. The fire risk assessment must be updated at least once a year. A minimum of four fire drills must be organised in a twelve month period. One of these must be carried out after dark. This is necessary to ensure the safety of residents and to ensure that staff are fully aware of action to be taken in the event of a fire. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Northwood DS0000010507.V375685.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 Northwood DS0000010507.V375685.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 3, 6 Evidence suggest that people moving to the home can be assured that they will be assessed to ensure that their needs can be met. These are generally undertaken satisfactorily. However, further improvements are required in specific areas related to pre-admission assessments to ensure that the needs of residents can be met at the home. EVIDENCE: The four residents, a relative and a friend of a resident interviewed informed the inspector that residents were well cared for and their care needs had been attended to. Northwood DS0000010507.V375685.R01.S.doc Version 5.2 Page 10 Comments made by residents and the relative included, “They take good care of me” “I am well cared for” and “Staff are friendly and caring.” Residents in the home were noted to be clean and appropriately dressed. A sample of three residents’ case records which was examined contained preadmission assessments. One was comprehensive. Two of these assessments were not sufficiently comprehensive as they did not include information on cultural background and spiritual beliefs of people who were admitted into the home. One did not have a pressure area (or tissue viability) assessment. Comprehensive assessments must be carried out prior to a service user being admitted into the home. This is to ensure that important information regarding the care needs of people who may be admitted into the home are obtained and appropriate care can be provided. These assessments must include the cultural background, religious beliefs and pressure area condition of the prospective resident (in addition to assessments regarding the physical health, mental health, potential risks, social needs and financial situation). This deficiency was brought to the attention of the manager who agreed that the required information would be obtained for future admissions. The manager stated that the home does not provide intermediate care. (Following the first visit to the home, the manager has provided certain information in the pre-admission assessments which were not recorded previously). Northwood DS0000010507.V375685.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 7, 8, 9, 10 Arrangements were in place to ensure that the personal, specialist healthcare, nursing and dietary needs of residents are met. Personal support provided was responsive to the preferences of people who use the service. The service was sensitive to the changing needs of residents. This ensures that the healthcare and personal needs of residents are met. The arrangements for the administration of medication was satisfactory. Improvements are however, needed in the care planning arrangements. EVIDENCE: The AQAA stated : Northwood DS0000010507.V375685.R01.S.doc Version 5.2 Page 12 “We meet the healthcare needs of residents very effectively and efficiently. We record and respond immediately to the needs of our residents.” Four residents, a relative and a friend of a resident who were interviewed, indicated that staff were attentive and had ensured that the healthcare and personal needs of residents are met. This was also confirmed by a healthcare professional who returned his completed survey form to us and by a healthcare professional visiting the home. Comments made by residents included, “They take good care of me” “I get my medication from staff.” “I can see a doctor if I need to. Staff would call the doctor” “I have been treated with respect.” The sample of three case records examined contained up to date plans of care. There was evidence that the healthcare needs of residents had been monitored and responded to. These plans of care had been reviewed monthly. There was evidence in the records to indicate that residents have access to healthcare services in the community and hospital. A record of medical and healthcare appointments had been kept. These included chiropody, dental and optician’s appointments. The case records also contained details of personal care provided. The manager provided us with a personal care monitoring chart. This chart provided details of personal care provided for all residents. Two of the care plans had been signed. The manager reassured us that the third would also be signed. Two of the plans of care examined did not contain care plans which addressed the mental, cultural and spiritual needs of residents. Such information is required to provide staff with guidance on any special aspects of the care required by residents. This was discussed with the manager who reassured us that care plans would in future be made comprehensive. She further stated that the spiritual needs of residents had been attended to. She stated that priests from different denominations had visited the home. We spoke to a local church clergy who confirmed that he had visited the home. This was also confirmed by a resident. One relative who returned a completed survey form stated that residents should be encouraged to do more for themselves in the areas of personal care and getting themselves dressed. This was brought to the attention of the manager. She stated that residents are encouraged to be as independent as possible and this is documented in their care plans. She gave an example of good practice where a resident was initially very dependent and had to have a high level of care. This resident is now able to move about freely and manages her personal care with minimal assistance from staff. She said there can be difficulties as sometimes relatives have a different view or object to the Northwood DS0000010507.V375685.R01.S.doc Version 5.2 Page 13 approach taken (to encourage residents to do as much as they can for themselves). The arrangements for the administration of medication were noted to be satisfactory. The home had the required policies and procedures and staff had been trained in the administration of medication. A record of daily fridge and medication room temperatures had been kept. These were satisfactory. Medication administration charts (MAR) were appropriately filled in. We noted examples of good practice. Staff knocked on the door prior to entering a resident’s bedroom. Staff were noted to be responsive and addressed residents in a respectful and caring manner. We also noted that the manager was aware of the individual needs and preferences of residents. This ensures that residents receive personal and individualised attention. Northwood DS0000010507.V375685.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 12, 13, 14, 15 The daily life, meal arrangements and routines of residents were on the whole, well organised. The service had a strong commitment to enabling residents to remain as independent as possible and engage in meaningful activities. Personal and family relationships were being maintained. Residents are confident that the home will provide them with support in accessing appropriate social activities and they will be able to choose what activities they can engage in. EVIDENCE: The home’s AQAA made the following statement: “We provide a lifestyle which matches with residents’ expectations and preferences. Personal choices and style of life have been encouraged eg. right to stay up, watch TV, open visiting hours, right to see and participate in their Northwood DS0000010507.V375685.R01.S.doc Version 5.2 Page 15 plans, choice of entertainment…and getting relatives to be involved in everything. ” We note that residents appear relaxed and able to move about freely in the home. Some were in their bedrooms while others were in the lounge. On both days, we note that staff made the effort to engage residents in activities and there was regular interaction with residents. The manager informed us that activities have been organised for residents. She stated that the notice board in the dining room contained information regarding a range of social activities and entertainment that the home provides. This was seen by us. Two relatives who returned completed survey forms to us suggested that there is a need to have more activities in the home to ensure that residents are stimulated. One suggested that residents be provided with mild exercise sessions and be encouraged to do more for themselves. This was brought to the attention of the manager. The manager stated that she had made effort to improve the activities programme. We were informed that residents are regularly taken to the garden when the weather is good. Bingo and skittles are being played. There are beauty sessions in the home each week and outings have been organised to the park and garden centre in nearby Crews Hill. Residents had also been on a trip to a school party. Residents interviewed said that they were generally happy with the social activities and entertainment that the home provides. One resident said that she enjoys gardening and taking care of the plants and flowers in the home. In view of the suggestions made by relatives, a recommendation is made that residents should be consulted regarding the activities provided. The manager agreed that this would be done. The arrangements for the provision of meals was discussed and the kitchen was inspected. It was noted to be well equipped and clean. The chef stated that it had been refurbished since the last inspection. Daily recorded temperatures of the fridge and freezer had been kept. These were satisfactory. A fire blanket was in place. The menus examined appeared varied and balanced. The manager informed us that residents had been consulted regarding their likes and dislikes and their cultural observances had also been noted. We were present when lunch was served. We note that this was prepared in an attractive manner and residents appeared to be enjoying it. Residents interviewed said that they enjoy the meals that the home provides. They confirmed that there is a choice of alternative main dish and the chef was willing to cook them special meals requested. The chef demonstrated a good understanding of the dietary needs and preferences of residents. One resident said that she looks forward to the meals. A relative made the following comments Northwood DS0000010507.V375685.R01.S.doc Version 5.2 Page 16 “The food and cooking is of a very good standard.” Northwood DS0000010507.V375685.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 16, 18 The arrangements for responding to complaints and for adult protection are satisfactory. The home has an open culture that allows residents to express their views and concerns in a safe and understanding environment. The required policies and procedures for safeguarding residents are in place and give the required guidance to staff. Regular training in safeguarding is provided for staff. EVIDENCE: In the area of Complaints and Protection, the homes AQAA statedc that they protect the rights of residents, residents and staff are happy and there had been no complaints against the home. They indicated that they invite relatives to communicate with them and share their views. The AQAA stated: “ We encourage expressions of concern or complaints. The policy ‘How to complain’ is framed and found in the main corridor. Complaints and concerns are dealt with asap.” Northwood DS0000010507.V375685.R01.S.doc Version 5.2 Page 18 Residents and those interviewed by us indicated that they were well treated and satisfied with the care provided to residents. One of the relatives wrote to us last year informing us that she was very satisfied with the care provided at the home and staff are well thought of. The home has an adult protection procedure. It included examples of abuse and guidance to staff on reporting allegations of abuse to Social Services and The CQC. The local authority guidelines were also available. The manager and her staff were aware of the policy and procedures for the protection of vulnerable adults. There was evidence in staff files that staff had been provided with adult protection training. The home has a complaints book. No complaints had been recorded since the last inspection. The manager explained that none had been received. When asked, residents said they knew who to complain to if they wanted to make a complaint. The home has a record of compliments received. Comments made included the following : “Thank you for the lovely Christmas party. You worked hard for us.” “A big Thank You for the way you gave her the much needed care.” “I do appreciate all the hard work and all the patience.” “Thank you for your kindness.” “I appreciated the delightful birthday party. It was so very kind of you.” No allegations of abuse or ill treatment had been made against the home since the last inspection in 2007. Northwood DS0000010507.V375685.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 19, 22, 23, 26 The home provides a physical environment that is aimed at the individual and specific needs of people who live there. It is clean, tidy and well furnished. The manager had ensured that the physical environment is well maintained. Residents can personalise their bedrooms to make them more homely. Overall, the home provides a pleasant and comfortable environment to live in. EVIDENCE: The four residents, one relative and a friend of a resident who were interviewed stated that they were happy with the accommodation provided for residents. The premises were inspected and found to be furnished to a high standard and well maintained. The manager stated that her husband had Northwood DS0000010507.V375685.R01.S.doc Version 5.2 Page 20 assisted with the maintenance of the home and repairs are promptly carried out. Bedrooms inspected had been personalised by residents with their own pictures and ornaments. They appeared cosy. All bedrooms have sinks. The laundry was located on the ground floor and the manager was aware of the appropriate arrangements for the laundering of soiled linen. The home had a walk-in shower for the use of residents with mobility problems. A chair lift is provided for those who have difficulty climbing the stairs. The chair lift had however, not been inspected by a qualified professional within the past twelve months. This was discussed with the manager who agreed to ensure that a safety inspection is carried out. Wheelchairs and zimmer frames are available for the use of residents who need them. A ramp is provided for access to the garden. No ramp is required at the front as it is on the same level as the ground. All areas of the home were clean and tidy. No offensive odours were detected. Plants and exotic flowers adorned the conservatory and communal areas of the home. The conservatory overlooks an attractive and colourful garden. There is seating (and umbrellas) in the garden. Overall the home provides a pleasant homely environment for residents. Northwood DS0000010507.V375685.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 27, 28, 29, 30 The service has a good recruitment procedure that is followed in practice. The manager recognizes the importance of training and tries to deliver a programme that meets statutory requirements. Residents and their representatives are satisfied with the staffing arrangements. EVIDENCE: 27, 28, 29, 30 Four staff who were on duty were interviewed on a range of topics associated with their work. They were able to provide appropriate answers and demonstrated a good understanding of the needs of residents. Staff stated that they had been instructed by the manager to treat all residents with respect and dignity regardless of their race, religion, culture, disability or sexual orientation. One staff stated that she would care for residents as if they were like members of her own family. Northwood DS0000010507.V375685.R01.S.doc Version 5.2 Page 22 Residents who were interviewed indicated that staff were always respectful, caring and polite. This was also the view of a relative and a friend of a resident who were present. We noted that staff were friendly and helpful during this inspection and visitors were welcomed and offered a cup of tea or other drinks. One relative made the following comment: “All staff showed a caring attitude and treat residents with respect and courtesy.” The duty rota was examined. Staffing levels were as follows: Am shift - 2 care staff Pm shift -2 care staff Night shift - 2 care staff (one on sleeping duty) The manager was supernumerary. Ancillary staff working at the home comprise one kitchen staff and a cleaner. Staff stated that the staffing levels were adequate and they were able to perform their duties. No concerns regarding staffing levels were expressed by those interviewed. The training records examined, indicated that staff had been provided with the required training. Following a requirement made in the last inspection report, we were provided with evidence that staff had been provided with infection control training. One new staff had been recruited into the home and none had left since the last inspection. The recruitment records examined indicated that the required recruitment procedures (including obtaining of satisfactory CRB disclosures, evidence of identity and two references) had been followed. Northwood DS0000010507.V375685.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 31, 33, 35, 38 People living in the home can be assured that the home is well run and the manager has the experience and ability to deliver a good quality of care and meet it’s stated aims and objectives. Records are on the whole, well maintained. There is a system for maintaining health and safety. Residents and their representatives are consulted regarding the care provided and the management of the home. Improvements are however, required in the area of health and safety. EVIDENCE: Northwood DS0000010507.V375685.R01.S.doc Version 5.2 Page 24 In the area of Management and Administration, the AQAA stated that the service has the necessary policies and procedures and is effective and efficient and able to meet the diverse needs of residents. The registered manager was knowledgeable regarding her responsibilities and the needs of residents. She stated that she regularly updated her knowledge by attending various seminars and training sessions. In addition, she had participated in the training courses organised for her staff. All those interviewed, including residents and staff were of the opinion that the home was well managed and the manager was approachable and diligent in her work. The informed us that there has been an increase in administrative work in the past year. This had placed extra demands on her time. We discussed with her ways in which this can be dealt with. She informed us that a computer had been purchased for the home and the home now has internet and email facilities. To assist her in her role, we suggested the possibility of administrative support for her. She stated that she would consider this. There was evidence that staff and residents meetings had been held and issues regarding the running of the home had been discussed with those present. The minutes of these meetings were available for inspection. Residents and staff interviewed were able to confirm that they had been consulted and the manager was responsive and sensitive towards ideas brought forward. We note from the minutes that the meetings were however, held at intervals of longer than five months. This was discussed with the manager and she agreed to increase the frequency of such meetings. She also said that some meetings had been held informally and she had not documented them. A recommendation is made for residents’ meetings to be held at least once in two months and these should be recorded. During these meetings residents should be consulted regarding the activities provided. This is to ensure that residents are regularly consulted and informed of matters affecting the home and there is documented evidence of this. Consumer surveys had also been carried out and three feedback forms were received. These were complimentary of the running of the home. The home had a current certificate of insurance. No residents’ financial records were examined. The manager stated that the home did not keep any money on behalf of residents. The home had a comprehensive range of policies and procedures. We discussed The Mental Capacity Act 2007 and it’s implications for residents and staff. The manager stated that she had attended relevant training in this area. However, the home did not have a policy and procedure. The home must have a Mental Capacity Act 2007 policy and procedure which includes guidance on Northwood DS0000010507.V375685.R01.S.doc Version 5.2 Page 25 The Deprivation of Liberty safeguards and a copy of the code of practice. This is required to provide guidance for staff and to safeguard the rights and best interests of residents. The manager agreed that this would be provided. Effort had been made to ensure the health & safety of those in the home. The manager was noted to be knowledgeable regarding fire safety and the necessary fire safety arrangements were in place. The weekly fire alarm tests had been carried out and documented evidence was provided. Fire drills and fire training had been organised and documented over the past twelve months. However, no fire drill had been carried out after dark. This is needed to ensure that staff are fully aware of action to take in the event of a fire occurring after dark. The fire risk assessment was dated 2007. This would need to be updated. Fire exits were kept clear. Staff interviewed were aware of the procedure to follow in the event of a fire. Significant incidents had been promptly reported to CSCI via Regulation 37 report forms. Safety inspections had been carried out on the portable appliances and gas installations. The five year electrical installations safety inspection had been carried out and the certificate was seen. We note that there was a large tree near the conservatory which appeared dead. This was brought to the attention of the manager. For safety reasons, this tree must be risk assessed by an appropriate professional and action taken to minimise any potential risk. This may result in either the removal of branches or the whole tree. The manager informed us after the inspection that this had been done and some overhanging branches had been removed. We suggested that there be further clarification with the professional involved to determine if the tree should be removed. One of the window restrictors in the home had a gap which was too wide. This was brought to the attention of the manager. She responded promptly and had the gap narrowed. Northwood DS0000010507.V375685.R01.S.doc Version 5.2 Page 26 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 2 X X n/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 4 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 2 X X 3 3 X x 4 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 2 3 3 X 2 2 Northwood DS0000010507.V375685.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 OP3 14 The registered person must ensure that comprehensive preadmission assessments are carried out before a prospective resident is admitted into the home. These assessments must include the cultural background, religious beliefs and pressure area condition of the prospective resident (in addition to assessments regarding the physical health, mental health, potential risks, social needs and financial situation). This is to ensure that the holistic needs of residents are attended to. This requirement has been repeated from the previous inspection. It was partially met and the requirement has been reworded. 2 OP7 15 Northwood Regulation Requirement Timescale for action 24/08/09 24/08/09 The care plans of residents must DS0000010507.V375685.R01.S.doc Version 5.2 Page 28 be comprehensive. The must address the holistic needs of residents and include plans for meeting the physical, cultural, social and spiritual needs of residents. This is to ensure that the holistic needs of residents are attended to. 3 OP37 12 The home must have a Mental Capacity Act 2007 policy and procedure which includes guidance on The Deprivation of Liberty safeguards and a copy of the code of practice. This is required to provide guidance for staff and safeguard the rights and best interests of residents. The manager agreed that this would be provided. 4 OP38 13(4) The large tree in the garden which appeared dead must be risk assessed by the appropriate professional and action taken to minimise any potential risk. This is necessary to ensure the safety of all those in the home. 5 OP38 23(4) The fire risk assessment must be updated at least once a year. This is necessary to ensure the safety of all those in the home. 6 OP38 23(4) A minimum of four fire drills must be organised in a twelve month period. One of these must be carried out after dark. Northwood DS0000010507.V375685.R01.S.doc Version 5.2 Page 29 31/08/09 24/08/09 31/08/09 31/08/09 This is necessary to ensure the safety of residents and to ensure that staff are fully aware of action to be taken in the event of a fire. 7 OP38 13(4) 23(2)(c) 17/08/09 A safety inspection of the stairlift must be carried out by a qualified professional. This is needed to ensure the safety of residents who use it. 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 OP31 Good Practice Recommendations The home should have an administrator. This is to ensure that the manager is provided with administrative assistance. 2 OP33 Residents meetings should be held at least once in two months and these should be recorded. During these meetings residents should be consulted regarding the activities provided. This is to ensure that residents are fully consulted and informed of matters affecting the home and there is documented evidence of this. Northwood DS0000010507.V375685.R01.S.doc Version 5.2 Page 30 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Northwood DS0000010507.V375685.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!