Inspection on 24/09/07 for Eastholme Nursing Home

This inspection was carried out on 24th September 2007.

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

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

Other inspections for this house

Eastholme Nursing Home 15/09/08

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Eastholme Nursing Home 74 - 75 South Park Lincoln Lincolnshire LN5 8ES Lead Inspector Sue Hayward Unannounced Inspection 24th September 2007 09:45 X10029.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 Eastholme Nursing Home DS0000069911.V347247.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 and Care Homes for Adults 18 – 65*. 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. Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eastholme Nursing Home Address 74 - 75 South Park Lincoln Lincolnshire LN5 8ES 01522 521956 01522 537371 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) Mr Kanagasooriam Ravivaruman Vacant Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24), Physical disability (4) of places Eastholme Nursing Home DS0000069911.V347247.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 with Nursing - Code N to people 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 Physical Disability - Code PD of the following age range: over 55 years - Maximum number of places 4 People whose needs come within the category PD will be accommodated as single occupants in any one of the following identified bedrooms :1, 2, 7, 9, 12a, 14, 15, 16, 17 and 18 The maximum number of people who can be accommodated is 24 2. 3. Date of last inspection New service Brief Description of the Service: Eastholme Care Home is a large, detached, three-storey, Victorian building with a ground floor, purpose built extension. It is situated in a cul-de-sac in a residential area to the south of the city of Lincoln, overlooking the common. The ownership and management of this home changed in April this year. It is now one of three homes in Lincolnshire owned by Mr. Ravivaruman. The accommodation is currently being substantially altered and refurbished to provide improved standards with some rooms now providing en-suite facilities. First floor rooms are accessible via stairs or a shaft lift. There is a small garden area to the rear of the property with car parking space and there is also car parking opposite the home next to the common. It is registered to provide personal and nursing care for a total of twenty-four people of both sexes over 65 years of age, up to four who may have a physical disability and who are aged over 55 years of age. Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 5 The current fees range from £348 - £533 per week depending on residents assessed care needs. Chiropody, hairdressing and newspapers are additional to the fees. This is a newly registered service. Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home was carried out by one inspector and formed part of a main inspection, which lasted six hours. Whilst it is a new service, information contained in the services previous inspection report was taken into consideration to ensure that action had been taken to improve areas that had been identified previously as not meeting standards. Information that the Commission for Social Care Inspection (CSCI) holds about the service such as its history since its new ownership and records of any incidents notified was taken into consideration. The acting manager and support manager had completed a self-assessment questionnaire giving important information about the service prior to the visit. This information was also used in the planning of the inspection and the compilation of this report. In view of there being insufficient time between the return of the self-assessment form and the visit surveys were not sent out to residents. Instead, these were left with the support manager at the time of the visit to distribute to residents and their representatives. Information from any that are returned will be used to plan for future inspections. The visit included following the care of three residents with a range of needs through checking records that are held about them, talking to two of them and to three staff members on duty. In addition two other residents were briefly spoken to as were a residents relative and two staff members. Short periods of observation were spent at various times of staff carrying out their duties. The visit focussed on key standards, which have the potential to affect residents’ health and welfare. The owner and support manager were present on this occasion and discussion was held about general outcomes of the inspection at the end of the visit. What the service does well: Care plans are well organised and contain sufficient information to ensure residents needs and how they are to be met are identified. There have been significant improvements to the environment, which has ensured that residents are living in a comfortable home, that is well decorated, furnished and maintained. For example some rooms now provide en-suite facilities. Bathrooms have been refurbished and baths replaced to enable residents a choice of whether to bath or shower. Additional equipment has been bought to assist residents who need help to move. Since the new owner has taken over catering and housekeeping staff hours have increased. Residents made mainly positive comments about the care provided and their satisfaction with the service. Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 7 What has improved 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. Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3 (Older People), standard 6 does not apply and standards 1 and 2 (Adults 18-65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a satisfactory admission procedure in place, which ensures residents’ needs are assessed and are able to be met. Satisfactory information about the service is made available to residents. EVIDENCE: The care records of three people resident in the service were checked on this occasion. This included a record of a person who had been admitted since the service was registered. Care records were generally well organised and up to Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 10 date and contained a range of information about residents such as communication needs, mobility, hygiene, recreational, medical and medication details. From this information care plans had been developed indicating the help and support needed. Since the last inspection the statement of purpose, and service user guide, documents, which give information about the home and service has been updated to reflect the changes of ownership of the home. They also contain information about the terms and conditions of residency and a summary of the previous inspection report. Information about the home was seen on display in the entrance hall and in a resident’s bedroom visited. A resident who had been recently admitted to the home confirmed the admission process. This had included a visit from the manager to assess his needs in hospital and to give him the opportunity to ask any questions as well as his relatives having the opportunity to visit the home on his behalf. He also confirmed that he had been given a copy of his terms and conditions relating to his residence at the home. There is an admission procedure for staff to follow and discussion with a relative confirmed that the changes to the homes ownership and management had been confirmed to residents via a letter and through discussion at a meeting held. Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 7, 8, 9 and 10 (Older people) and 6, 9, 16, 18, 19 and 20 (Adults 1865). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are well organised and reflect the individual needs of residents to help ensure their health and welfare as well as taking into account their personal preferences. There are satisfactory policies and procedures in place about the administration of medication but staff need to ensure these are consistently followed to ensure residents safety. The privacy and dignity of residents is well respected. Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 12 EVIDENCE: Care records were in place for all residents whose records were checked on this occasion. They were well organised generally reflected the assessment information obtained and also included documented assessments were risks had been identified. They included information about residents health and medication needs. There is a system in place to regularly audit care plan information, which helps to ensure that they are up to date and reflect accurately residents’ needs and how to meet them. Staff had a good knowledge of the care needs of residents asked about and were observed to be polite and courteous when speaking to residents. Residents made positive comments about the standard of care provided and felt their privacy was respected in the home. For example a resident said “staff have been so kind”. Care plans contained some information, which reflected resident’s spiritual and cultural needs. For example, information in a care plan contained guidance for staff to follow about how best to communicate with a resident whose first language was not English. Care plans had been signed by residents or their relatives demonstrating their involvement with them. Records also included information, which demonstrated that health care was well monitored through visits and referrals to and from other professionals such as doctors. A resident said he could “have the doctor to visit when I want”. There are satisfactory policies and procedures in place relating to the safe keeping and storage of medication. Nursing staff give out medication using a pre-packed system, which has been prepared by a local pharmacist. This is a recognised method, which helps to ensure the safety of residents. None of the current residents administer their own medication. A staff member was observed for a short while giving out medicines. It was observed that she checked the medication sheet prior to dispensing medications and always locked the trolley up securely whilst giving out medicines but occasionally handled medicines and signed records before ensuring a resident had taken it. This practice is potentially unsafe although it is recognised that the staff member gave a satisfactory answer to what she would do to rectify this if a resident subsequently did not take the medication. Medication storage arrangements were satisfactory and the support manager confirmed that a pharmacist was due to visit the next day to check and provide guidance on medication systems in place. Staff confirmed that they had had training about the safe administration of medicines. Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 (Older People) and 12, 13, 15 and 17 (Adults 18 – 65) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are some opportunities for residents to participate in social and leisure activities. The meals provided are well balanced and take into account residents personal preferences and special dietary requirements. Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 14 Visitors are made welcome and residents have as far as possible choices as to how they lead their lives. EVIDENCE: Residents records checked did include details about matters such as residents’ recreational and social needs and of any specific dietary requirements or food preferences they had. Staff were aware of these, for example, which residents needed specific diets to maintain good health and of their particular food preferences. A staff member was employed specifically to provide recreational activities for residents however this post is currently vacant and whilst care staff are providing some activities, staff said this was on a less frequent basis. Discussion with the management team confirmed that they had now recruited to the post and acknowledged that this was an area that needed further development and wanted to promote more involvement with the local community. Information about the activities available was seen on the notice board. A small book library with some books being available in large print was also seen. Records checked demonstrated that residents had the opportunity to put forward their views and suggestions about the activities programme and outings they would like to see arranged. Records demonstrated that three residents had visited RAF Waddington, quizzes had taken place and a strawberry tea had been arranged. Staff said contact is made with local church representatives to visit residents if they wish. There is a mini bus for trips out which can be also be used to transport people who need to use wheelchairs. A resident confirmed that he made his own decisions and gave an example that he had been asked whether he wished to celebrate his birthday with a party by staff. He said he had declined this and staff had respected his wishes. He also confirmed that he was able to have visitors when he wished. Another resident confirmed that he is able to go out for a walk independently when he wishes. Menus checked showed that residents have a choice of foods at each meal. Catering staff hours have increased which means that care staff have more time to spend with residents. A resident made the comment she had enjoyed the food provided and it was noticed that a fluid chart was in place for a resident with higher dependency needs to ensure her well being. Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 (Older People) and 22 and 23 (Adults 18-65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are satisfactory systems in place to raise concerns and as far as possible protect residents from abuse. However, records do not consistently show the actions taken to resolve any matters raised to ensure residents welfare. EVIDENCE: Before the visit took place a copy of the home’s statement of purpose and service user guide was provided. This contained information about what to do and who to speak to if people have concerns. During the inspection information about how to raise concerns was seen on display in the home. There was also a suggestion box, which the owner confirmed is kept locked and only he has the key. He confirmed that he checks this regularly. The commission have not received any complaints about the service since its registration. Information provided by the acting manager and support manager before the visit showed that there had been four complaints made all Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 16 of which had been received and addressed, however the record kept of complaints only contained details of one of these. This was discussed with the management team at the time and it was agreed to ensure in future that records would be kept to fully reflect actions taken and outcomes of any concerns or complaints raised. (See also comments made at the management standards) Residents and a relative spoken to made comments which showed that they knew who was in charge and would feel comfortable to raise any concerns they may have with staff. A resident said “ I would soon tell them if I wasn’t happy”. A relative said that she was also invited to attend residents meetings and put her views forward in view of her relative being unable to do so herself. Staff had a satisfactory understanding of the complaints and safeguarding adults’ procedures and how to report such matters. A copy of the Lincolnshire Safeguarding adults’ procedures was also available for staff to refer to if needed. Both staff seen said they had also had training. Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 22, 24 and 26 (Older People) and 24 and 30 (Adults 18-65). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A clean, tidy and well-maintained environment is provided for residents where they are able to personalise their rooms. This helps to ensure residents live in a safe and comfortable environment. EVIDENCE: Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 18 There has been substantial work done to improve the environment of the home, which was continuing on the day of the visit. Rooms have been redecorated and there are now eight rooms, which offer en-suite facilities. New equipment has been purchased such as hoist and bathrooms have been refurbished and are more accessible for residents to use. Some doorframes have been widened to enable better access for residents. It was confirmed by the management team that further work planned includes refurbishment of the kitchen and a further extension to the home to offer twelve more bedrooms and a larger dining room. The management team are aware of the need for any extensions or alterations to the property to meet National Minimum Standards, to obtain approval from the building/planning department, fire safety approval and environmental health approval as well as applying to the commission to vary their terms and conditions of registration. All areas of the home seen on this occasion were clean and tidy and well decorated. Four residents rooms were seen on this occasion. They were comfortably furnished and residents had been able to make them more homely with their own personal effects. Where needed they contained equipment to ensure residents comfort such as pressure mattresses. Low surface temperature radiators were seen in rooms to ensure residents safety. Bedrooms and bathrooms are lockable to promote residents privacy. A resident said that his room was cleaned daily. He also made comments which indicated that he was kept informed about any alterations needed for example knew that the electrical sockets in his room were due to be moved at the end of the week so that extension leads did not have to be used. New equipment has been purchased for the laundry including a new washing machine and tumble dryer. The management team said that a new sluice is had also been ordered. There are a range of policies and procedures in place in relation to health and safety matters. A representative from the environmental health department last visited the service on 05/07/07 some recommendations were made. The support manager confirmed all had been attended to. Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 (Older People) and 32, 34 and 35 (Adults 18-65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are satisfactory staffing arrangements in place to meet the current needs of residents. Staff are trained to ensure they have sufficient knowledge and skills to provide appropriate care. Residents are as far as possible protected by a thorough staff recruitment process. EVIDENCE: Discussion with staff and observations made during the visit indicated that there were enough staff on duty to meet residents needs. For example at lunchtime sufficient staff were available to assist residents who needed help to eat their meal. Four staff were on duty at the time of arrival, which included a qualified nurse as well as the owner, cook and housekeeper. Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 20 Discussion with a staff member confirmed the current staffing levels which ensures there are always three care assistants on duty in the morning, two care assistants in the afternoon and one at night. In addition there is a qualified nurse on duty at all times, catering staff and housekeeping staff daily. A maintenance person is also employed as well as an administrator. Staff spoken to and training records checked confirmed they had participated in a range of training such as basic food hygiene, safeguarding adults, manual handling first aid and fire training. Two care staff have obtained a nationally recognised vocational award in care in addition there are six qualified nurses employed and four from abroad who are in the process of completing an adaptation course to enable them to work as qualified nurses in this country. Staff felt supported in their work by the management team through the supervision and appraisal system in place and team meetings, which are held. A staff member described the management team as approachable and there is an “on-call” system worked at weekends should staff need support. Residents commented positively about staff. One said “I don’t have long to wait for help to come when I ring my bell”. Staff were observed to be attentive to residents need throughout the visit and were kind and courteous when talking to residents. The records of recruitment of three staff members were checked on this occasion. These demonstrated that a satisfactory process was followed including obtaining references and a criminal records bureau check for each person to determine their suitability to work with vulnerable people. Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 37 and 38 (Older People) and 23, 37, 39, 40, 41 and 42 (Adults 18–65). Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 22 The service is being satisfactorily managed and there are systems in place to ensure residents views about the service are sought in order to develop it further. However, the lack of up to date and accurate records in some instances to show how aspects of the service are monitored has the potential to put residents’ health and safety at risk. EVIDENCE: The service has been without a registered manager since August however discussion with the management team indicated recruitment to this post is in progress. Satisfactory arrangements have been made in the interim to ensure that there is adequate management support available which includes a current staff member acting in this capacity with further support from a manager of one of the sister homes. The owner also takes an active role in the operation of the home and staff said that he is available on a daily basis. There is also an “on-call” system out of office hours should management advice or support be needed. Discussion and records demonstrated that there are various systems in place to monitor the quality of the service being provided. This includes seeking the views of residents and their relatives through meetings held and questionnaires, talking to residents and relatives individually and through the comments, complaints and suggestions box in place. Records were available to demonstrate that audits of different areas of the home such as the kitchen, residents care plans, and an infection control audit had taken place. From the results of these, action plans are produced in order to improve aspects of the service. Comments from residents and a relative demonstrated that they knew who was in charge and felt able to raise any concerns if they had any. There are a range of policies and procedures in place relating to health and safety matters. A sample of records to demonstrate the maintenance of some areas of the home was checked. This included the fixed electrical wiring, which demonstrated that action had been taken to carry out the urgent work needed and the system was satisfactory. Records were not always in place to demonstrate how aspects of the service are monitored. For example it could not be demonstrated that the fire risk assessment had been reviewed, nor that weekly checks were being carried out to ensure the fire alarm system was in working order. In view of their being a number of structural changes to the premises this needs to be done to ensure residents are kept safe. The management team said that the risk assessment was in the process of being reviewed and agreed that records would be kept to demonstrate the weekly checks of the fire alarm system that take place. Neither were records up to date detailing any concerns and complaints Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 23 received. The owner acknowledged that he had not been completing monthly reports about his visits to monitor the home, which are required by the law, although agreed to do so in future. The arrangements in place to safe keep any money or valuables on behalf of residents are satisfactory although again record keeping systems need to be improved and the support manager agreed to address this. Residents and a relative spoken to made positive comments about the care and accommodation provided. Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 2 36 X 37 2 38 2 Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 25 New service 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 Timescale for action 24/11/07 2 OP12 16(2)(m) 3 OP37 17 (2) Schedule 4 (9, 11, and 14) Staff must adhere to policies and procedures when giving out medicines to ensure that medicines are not physically handled prior residents receiving them and records are not signed until after residents have taken their medication. This is to ensure residents are adequately protected. There must be sufficient staff 24/11/07 time available for the social and recreational needs and wishes of residents to be met within the home and local community. This will ensure as far as possible that they are able to lead fulfilling lives, which meets their needs and wishes. There must be a system in place 24/11/07 to ensure that the following records are up to date and contain accurate and sufficient detail in relation to the following: • • • Complaints Tests of the fire alarm system Records of all transactions of any money or valuables Version 5.2 Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Page 26 in safekeeping. This will ensure residents are well protected. There must be reports available for inspection to demonstrate areas of the service, which is being monitored to ensure the health and welfare of residents. 4 OP37 26 (4)(c) 24/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP38 Good Practice Recommendations In view of there being substantial changes to the property it is recommended that the fire risk assessment be reviewed and updated. Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lincolnshire Area Office Unity House The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Eastholme Nursing Home DS0000069911.V347247.R01.S.doc Version 5.2 Page 28 © 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. Eastholme Nursing Home DS0000069911.V347247.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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