Inspection on 21/07/08 for Northlands House Nursing Home

This inspection was carried out on 21st July 2008.

CSCI found this care home to be providing an Good service.

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

Northlands House Nursing Home 31/08/07

Northlands House Nursing Home 13/06/06

Northlands House Nursing Home 07/12/05

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Northlands House Nursing Home 6 Westrow Road Southampton Hampshire SO15 2LY Lead Inspector Unannounced Inspection 21st July 2008 10:10a 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 Northlands House Nursing Home DS0000064233.V367607.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. Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Northlands House Nursing Home Address 6 Westrow Road Southampton Hampshire SO15 2LY 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) 02380 717600 02380 717601 baxtermo@bupa.com www.bupa.co.uk BUPA Care Homes (CFC Homes) Ltd Mrs Moira Baxter Care Home 101 Category(ies) of Old age, not falling within any other category registration, with number (101), Physical disability over 65 years of age of places (101) Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service user under the age of 65 may be admitted on the 29.12.06 Date of last inspection 31st August 2007 Brief Description of the Service: Northlands House Nursing Home is a purpose built nursing home that was registered and opened in July 2005. The Home is owned and run by BUPA and is part of a joint initiative with Southampton City Council, who owns the land the building is on. As a consequence of this joint working, Southampton City Council have a remit to be able to accommodate 72 of the 101 beds registered for elderly people who have been assessed as needing nursing care, who are physically disabled and who are residents within the Southampton city boundaries. The home is on three floors and all rooms are single occupancy with en-suite shower room facilities. The interior and fixtures and fittings have been completed to a high specification with lifting aid and adjustable beds available throughout the home. The house is situated in a quiet residential area close to the city centre. The service users have the benefit of large well-maintained gardens that are accessible to wheelchair users. The home’s fees range from £575-£1081 per week. There are extra charges for items such as chiropody, hairdressing and telephones. Northlands House Nursing Home DS0000064233.V367607.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 An unannounced visit to the service was undertaken as part of the inspection on the 21st July 2008. The process included a tour of the service where a number of the bedrooms, communal areas, kitchen, and bathrooms were viewed. As part of case tracking 7 staff and 8 service users views were sought and care records were looked at. Information gained from the pre inspection questionnaire was also used and included in this report, as was information gathered by the commission since the last inspection to contribute in assessing judgements in this report. Positive comments were received from the service users regarding the care that they were receiving at the home. The commission received 14 surveys from people using the service and 8 from the staff. The residents’ surveys also contained input from their family as appropriate. Care practices observed at the time of the visit showed that the staff and the service users had developed good relationships and care was provided in a respectful manner. Comments that we have received can be found in the body of the report. What the service does well: The home has an assessment process in place in looking at the needs of both potential and existing service users to ensure that the home can meet their needs. The home has continued to develop the activity programmes to the satisfaction of the service users. The service users are provided with a warm, homely and well- furnished accommodation that is maintained to a high standard that they said met their needs. The care plans and records of care given were good that ensured that residents received the support and help they required. The management system and procedures in the home worked well including, dealing with complaints, staff supervision and the service users’ money. Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 6 The service has staff that are skilled and knowledgeable about the care needs of older people and regular training was available to them. 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. Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 7 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 Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 8 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 2,3,6 The pre admission assessment process is good and ensures that the residents’ needs are assessed and the home can meet them. Residents are now provided with terms and conditions of residency. The home does not provide intermediate care. EVIDENCE: We looked at the care records of four of the residents as part of case tracking. This showed that the manager undertook a pre admission assessment prior to admitting someone to the service. The manager explained that the pre Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 9 admission assessment process in place allows staff to use this assessment and develop the care plans on admission. Assessments of needs included dietary needs, likes and dislikes, manual handling assessments, skin integrity, communication, hearing. The manager reported that all the residents have a care plan in place within 72 hours of admission. Comments we received indicated that the relatives visit the service and it was not always possible to do so due to their frailty. Comments included: “My daughter visited and this is the right place for me”. Other comments were that the social services dealt with the admission arrangements. The staff reported that people are offered the opportunity to visit and spend some time looking around. The last visit report required that the residents were provided with the terms and conditions of residency. A sample of three residents records seen showed that this has been put in place. The staff reported that people did wait a long time to receive the local authority contracts. The manager confirmed that the service does not provide intermediate care. Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans and records of care given were good. Staff had clear information about the support that the service users required with their care. The health care needs and access to external agencies are well managed. The medication management was satisfactory, further development of the management of ointment/creams is needed to ensure that people are protected at all times. The service users are treated with respect and dignity and their right to privacy maintained EVIDENCE: Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 11 The care plans of 4 of the residents with varying care needs were looked at as part of this visit to demonstrate how the home plans to meet the needs of the residents. We found that the care plans were detailed and contained good information about the assessed needs of the service users and actions required in order to meet them. These included assessments such as manual handling, dietary needs, falls, continence, medication, and the personal care needs. Care plans including night care were put in place to demonstrate how these needs would be met. There was evidence that the service users were involved in these assessments. Daily records were maintained of the care given. There was evidence of regular reviews of the planned care to reflect any changes in the needs of the residents in the records seen. The home was developing the plan of care further to include end of life care. This was an emotive subject and staff provided support in a sensitive manner. The care plans for two of the residents who had been assessed as at risks of falls had bed rails assessments completed and consents gained as appropriate. We noted that the bed rails protectors were not secured safely as required for one of the residents we visited. The senior nurse took immediate action and we were assured that this would be reiterated to the staff to ensure that the residents are not put at risk of injury/ entrapment. We looked at the care plan for one of the resident who was receiving Percutaneous Endoscopic Gastrostomy (PEG) feeds at the time of the visit. There was clear record of the type of feeds and amount to be given clearly recorded. Other information included care of the PEG site and flushing of the tube. Two other residents were receiving thickening agents in their fluids as they were assessed as risk of choking. Care plan contained some detail of this and should be further developed. A copy of the assessment was not available and must be included in their current plan of care to inform practice. The thickening agents found in the residents rooms were labelled and we observed that this was brought into the dining room for one of the service user at lunchtime. Staff must ensure that the thickening agents as prescribed are labelled with the name of the service user as this was not available for one of them. Comments from the service users included “ I have no grumble and I am very happy here.” Another service user said “the care is excellent”. Other comments were “ I get all the help I need and the staff are good.” A relative commented “ Very happy here, she has definitely made the right choice”. Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 12 Other comments were: “keep waiting to go to the toilet” “Not enough staff on sometimes, so things get missed.” This was discussed with the manager at the time of the visit. The manager reported that there is one floating staff on the early shifts to ensure that the residents do not wait long when they require assistance. All the service users are registered with a surgery. The manager reported that the home had good relationship with the local primary care trust and the service users were supported to access health care services as required. The service has the added facility of an in house doctor available for daily consultation/ care. This provides the residents with the continuity of care and regular reviews of their care. . Pressure relieving mattresses and cushions were available for the prevention and treatment of pressure ulcers. The home has a medication policy and procedure and a sample of staff signature who were responsible for the administration of medication was in place. A sample of the Medication Administration Record (MAR) seen at the time of the visit showed that all prescribed medications given were recorded appropriately. The staff confirmed that only the registered nurses were responsible for medication management. Regular update in medication was available. A medication audit was not available and should be developed, as part of medication monitoring/ management The home maintained satisfactory records of medication received and discarded. All medication was stored securely and included controlled drug. We noted that there were some creams/ ointments that were in the residents’ rooms and were not labelled with their names. This was brought to the attention of the senior nurse and manager. Staff reported that sometimes relatives brought these in. The manager is aware that any treatment/care administered must be recorded in the appropriate care plans. The manager reported that staff had rectified the labelling of the ointment by the end of our visit. The drug fridge temperature was monitored, however staff had not taken any action when the reading was below the recommended temperature. This was brought to the attention of the manager who later confirmed that the thermostat had been adjusted. As discussed staff must ensure that prescribed analgesia that are not part of the monitored dosage system must be dispensed from the individual’s own prescribed containers. Comments received and care practices observed showed that people were treated with respect and personal care was provided in the residents’ rooms. A comment received from a relative was: “My mother is sometimes washed in her private areas by a male member of staff. Although the staff are extremely Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 13 nice, she feels very embarrassed by this. She would feel more comfortable with a female”. This was brought to the attention of the manager who stated that this information formed part of the assessment process on admission. This will be reviewed and staff made aware of people’s personal choices and preferences. The manager must ensure that the residents’ choices/ preferences regarding their care are clearly identified in their plans of care and the staff adhere to these. Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The social and recreational facilities for the service users have improved and managed well. The service users are supported to maintain links with the community and their family and friends. The service users autonomy and choices are respected in their activity of daily living. The meals at the home offer the residents variety and choices to their satisfaction. EVIDENCE: The home has a planned and varied programme of activities for the service users. The home employs three activity coordinators who are available daily between the hours of 11-5pm. The manager reported that the hours between 11-12 is dedicated to people who are unable to join in group activities and can Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 15 enjoy 1: 1 activity sessions. The staff also assisted the carers with feeding the residents at lunchtime. On the day of the visit the residents were observed taking part in a quiz. This was attended by a large group of residents and WAS interactive. Another group of four residents were observed in another room playing a card game. The manager reported that there were five residents who attended a ladies/gentleman club twice a month in the community. We noted that there was a large number of visitors to the service and a record of these visits were maintained at the home. The residents and their relatives we spoke to on the day confirmed that there was no restriction on visiting. Comments we have received from our surveys included: “There are activities available and I choose not to take part”. Others said that they enjoyed the games and the quiz in particular. The planned activity programme was displayed in the entrance hall and some of these included bingo, puzzles and games, sing along, gardening club, arts and crafts. Other activities include external entertainers who visited monthly and themed meals. The recent themed meal was French with “ cruising to France” and the next one has a Spanish flavour. The hairdresser was attending the service on the day of the visit and a number of the residents were having their hair done throughout the day. The hairdresser came in twice a week and the hairdressing salon was well organised. We spoke to a number of the residents who were all complimentary about the hairdressing service available. One of the residents talked about her involvement with the salvation’s army throughout her life and liked to keep in touch with them. The manager stated that they did visit the home on occasions. The vicar also visited on a monthly basis and communion was available to the residents. The home has a planned menu that is rotated on a four weekly basis. The staff assisted the residents with their choice from the menu cards. The chef had good knowledge of the residents’ likes and dislikes and information about type of meals such as diabetics, pureed and soft meals as required. Cooked breakfast was available to the residents as required. Comment cards received and the service users spoken with said that the meals were “ very good” and hot and cold drinks were available at all times. Comments included “excellent food” and “good choice” Other comments were “there is always plenty food here”. One of the comments was that “ choice was minimal for vegetarian”. However a resident we spoke to who happened to be a vegetarian said that there was plenty to choose from and the meals were good. Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 16 Another comment from the survey was “ always end up with sandwiches every night”. We looked at the menu choice for teatime and found that a light cooked snack was also available. We observed the lunchtime meal on the day of the visit. The service had invested in hot trolleys on each floor to ensure that the meals are served hot as needed. We noted that there was a good system in place and staff were available to assist with meals as required in a sensitive manner. Meals were not rushed and the food looked well presented, appetising and balanced. The chef discussed the scoring system in place to ensure that the nutritional needs of people are adequately met and they receive the five recommended portions of vegetables and fruits per day when devising the menu. Northlands House Nursing Home DS0000064233.V367607.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaint management is good and the service users are confident that their complaints would be listened to. Staff have clear understanding of adult protection and action they must take. EVIDENCE: The home has a complaint policy and procedure that staff and the service users spoken with said that they were able to use. Comments included “there is nothing to complain about” and “I am very happy here”. Two residents spoken with said that they would speak to the matron if they were unhappy with anything. Comments from our surveys showed that people had the information on how to make a complaint. The home maintained a complaint log. This showed that the service had received a number of compliments and two complaints. Record seen showed that both of these had been resolved. The manager was pro active in dealing with any concerns raised. The investigation process was thorough and the manager involved social services in one the investigation and record of these were kept. The manager discussed that service has an internal auditing system to monitor complaints received. We received information regarding misappropriation of controlled medication involving a qualified staff member. The home took appropriate action and the Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 18 staff had been dismissed. The manager reported that the final outcome of the investigation was not known. As part of safeguarding, the provider must confirm to us in writing, action that had been taken including any referrals to the nursing professional body and POVA as appropriate. The service had information on the safeguarding adults process and this information was provided to the staff as part of their induction. Staff had clear understanding of what constituted abuse and said they would report to the manager. Northlands House Nursing Home DS0000064233.V367607.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides the service users with a high standard, clean and wellmaintained accommodation that meets their needs. The infection control procedures at the home are available, however staff practices were inadequate and put the residents at risk. EVIDENCE: A tour of the premises was undertaken as part of the visit and a number of bedrooms, communal areas, bathrooms, and kitchen were viewed. It was evident that the home has an ongoing programme of refurbishment. The home was warm, bright, clean and homely. Furnishing was of very good standard and appropriate to the needs of the service users. The service users are provided with ample communal areas where a variety of activities are Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 20 undertaken. Most of the bedrooms seen have views of the garden. The service users’ bedrooms were personalised with pictures, televisions, small item of furniture and family photos. It was evident that the service users are encouraged to bring in items of personal belongings on admission. One of the comments we received was “room always clean and tidy and am very happy here.” Information on infection control was available. Staff practices observed indicated that they were aware of them and used protective gloves and aprons as needed. The sluice area was well kept and colour coded laundry bags were used as part of infection control. However we observed one staff member carrying soiled laundry inappropriately. This was brought to the attention of the manager and staff must ensure that procedure for the transfer of soiled laundry is adhered to in order to protect people using the service. Northlands House Nursing Home DS0000064233.V367607.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing numbers are adequate to meet the present needs of the service users. The home has system in place to ensure that staff have the skills to deliver care safely. However further development in NVQ training is needed. The recruitment process is lacking in some part and does not fully protect people using the service. EVIDENCE: The home has a duty roster for nurses and carers and a separate roster for ancillary workers. The service is divided into three floors and the manager reported that staff are delegated and work in a specific area/ floor for a period of six months and over. This provided the residents with some continuity. The ground floor had 2 trained nurses and 7 carers, there are 2 trained staffs and 7 carers on the first floor and the top floor had 1 trained staff and 5 carers. The night staff included 3 trained staff and 7carers. Staff and 5 service users spoken with confirmed that they felt that there were adequate staff to meet their needs. Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 22 The comments were ”they are all very kind and help me always” “Staff does their best” Other comments were “Keep waiting to go to the toilet.” “It depends on staff”. “Not enough on sometimes so things get missed.” One comment was about the poor language skills of the staff. These comments were shared with the manager at the time of the visit. We observed that staff were available and the call bell was responded to when we rang on behalf of one of the residents. The manager must ensure that there is a continuous review of staffing to meet the assessed needs of people using the service as their dependency fluctuates. The staff have an induction programme in place and the manager reported that all staff complete the induction as per company’s policy. The records of induction should be available at the service as discussed at the time of the visit. There is a detailed training programme in place. As part of induction, the staff completed moving and handling training to ensure that staff practices did not put the residents at risk. Information from the AQAA indicated that of the 50 permanent carers 11had completed their National Vocational Qualification (NVQ) 2 and 6 were working towards this qualification. One bank staff had achieved this qualification and 3 of them were undergoing this training at the present time. Further development in NVQ training is needed to ensure the service meets the requirement for NVQ trained staff. We looked at a sample of 4 staff records as part of this visit. All staff completed an application form and checks were carried out such as criminal record bureau (CRB) and POVA first checks. The records were unclear regarding the dates that the staff started work and one of them showed that they had started work prior to CRB clearance. Staff confirmed that the member had not started work but was undergoing their induction at the time. The staff’s file for one staff member showed that there was no record of a visa clearance to indicate that they are eligible to work in this country. As discussed Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 23 the manager must ensure that references are checked to ensure that they are from the last employer as required as this was unclear for one staff. The manager reported that this would be brought to the attention of the company, as she was not directly involved in seeking out references. Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 24 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): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear management process in place and staff are supported in their work. The financial interests of the service users are safeguarded through good accounting. The process of seeking the service users’ views is satisfactory. There is a satisfactory procedure in place to ensure the health and safety of the service users is promoted. Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 25 EVIDENCE: The home has a registered manager who is also a registered nurse with a number of years experience in the care of the elderly. The manager discussed the management process that included a senior “sister” on each floor including night duty to support the staff and monitor care practices. The AQAA tells us that as part of improving the management were planning to have ongoing training and supervision for the staff. Other areas of improvement would focus on the residents’ involvement including regular residents’ meetings chaired by them. Service users spoke kindly of the manager and said that she was “ here if you needed her”. It was evident from interaction observed that the staff and the service users had developed good relationships with each other. Comments from service users included “the staff are kind” Following the last inspection the manager was required to develop and put inn place a structured supervision programme for the staff. This has been developed and the manager reported that the senior staffs are each responsible for a group of staff. This will be further looked into at the next visit to ensure that this is embedded in practice. Information we have received indicated that there is an ongoing programme for the servicing of equipment. The environmental officer had visited in the last 6 months and the chef reported there had been recommendations that have been met. The manager reported that there is an internal auditing process in place. Monthly audit as Regulation 26 are completed and reports of these were maintained. The manager stated that an audit to seek the views of the residents and other stakeholders was planned for, later the summer this year. A sample of the personal allowance as managed by the home was looked at. There was a good system in place and all the service users’ money were kept separately. Receipts and invoices were maintained of transactions. All transactions undertaken with the service users were recorded. The administration manager stated that the company also carried out an internal audit of the residents’ finance at regular intervals. Substances that are hazardous to health (COSHH) were maintained safely at the time of the visit. As previously reported staff practices in infection control was lacking and can be to the detriment of the residents. Northlands House Nursing Home DS0000064233.V367607.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 3 3 X X N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 27 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 OP26 Regulation 13(4) Requirement The registered person must ensure that staff follow the procedures for infection control and their practices do not put the residents at risk. The registered person must ensure that all necessary checks are completed prior to employment to include relevant references and their entitlement to work. Timescale for action 15/09/08 2 OP29 19 15/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Northlands House Nursing Home DS0000064233.V367607.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Northlands House Nursing Home DS0000064233.V367607.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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