Inspection on 31/08/07 for Northlands House Nursing Home

This inspection was carried out on 31st August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Northlands House Nursing Home 21/07/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Northlands House Nursing Home 6 Westrow Road Southampton Hampshire SO15 2LY Lead Inspector Chris Johnson Unannounced Inspection 31st August 2007 10:00 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.V343029.R02.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.V343029.R02.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) Limited 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.V343029.R02.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 13th June 2006 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 own 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 home’s fees range from £535.08 to £850.00 per week Northlands House Nursing Home DS0000064233.V343029.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this inspection was to assess how well the home is doing in the meeting of all key National Minimum Standards, compliance with regulations, previous requirements and to assess what the outcomes are for people who live at his home. The findings of this report are based on a number of different sources of evidence. These included: An unannounced visit to the home, which was carried out on 31st August 2007 and lasted for approximately twelve hours. All regulatory activity since the last inspection was reviewed and taken into account including any notifications sent to the Commission for Social Care Inspection. The manager completed a self-assessment document prior to the visit and surveys were sent to twenty-five people living at the home, thirteen relatives and one healthcare professional. Twelve of the people living at the home returned a survey, as did eight of their relatives. During this visit a tour of the premises was completed that included looking at people’s bedrooms and all communal areas of the home. Staff and care records were inspected. Some members of staff were spoken with and others were observed during their day-to-day interactions with those living at the home. The inspector held a meeting at the home to enable people to discuss their experiences’ of life in the home. This was attended by twelve of the people living at the home, two relatives and one visitor. The inspector spoke with other people individually. A senior nurse assisted the inspector throughout the visit as the manager was on leave. What the service does well: What has improved since the last inspection? Northlands House Nursing Home DS0000064233.V343029.R02.S.doc Version 5.2 Page 6 Improvements continue to be made to the care planning process and the level of information recorded. The garden has been improved since the last inspection and now provides people with plenty of seating areas, paths and ramps and is suitable for wheelchair access. The home has recently installed additional dishwashers and hot trolleys and it is anticipated that this will assist in maintaining meals at a suitable temperature and speed up the serving process. 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.V343029.R02.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.V343029.R02.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): 2,3 and 6 People who use 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. Peoples’ needs are fully assessed prior to admission so that the individual and the home can be sure that the home is right for them and will meet the person’s needs. People living at this home do not have terms and conditions detailing their rights and therefore their rights may not be fully protected. EVIDENCE: Northlands House Nursing Home does not provide intermediate care. This standard is therefore not applicable and was not assessed. The home has a block contract with social services for seventy-two beds. At the time of this visit all of these places were full. The remaining places are made of people whose fees are paid privately. Northlands House Nursing Home DS0000064233.V343029.R02.S.doc Version 5.2 Page 9 A requirement had been made at the last inspection that people were to be issued with terms and conditions of residency to include the room that is to be occupied and the amount and breakdown of fees. At the time of this inspection there was no evidence that any action had been taken to address this. Neither contracts or terms and conditions were found for any of the people case tracked. None could be located for anyone. Responses from surveys and discussions with people would support this. During a meeting with people living at the home the majority said that they had neither a contract or terms and conditions. One person said that they had been given a contract although this had not been explained to them. Responses from service user surveys were that 10 of the 11 people said that they had not had a contract. Pre admission assessments and care notes were looked at for people who had moved into the home since the last inspection. These demonstrated that people had been assessed prior to admission to determine whether the home could meet their needs. Assessments are only undertaken by the manager or a senior nurse and these are undertaken in whatever setting the referral has come from, which is generally via the local hospitals. Care management assessments had been obtained where appropriate as had transfer notes from the person’s previous setting. Northlands House Nursing Home DS0000064233.V343029.R02.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 and 10 People who use 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. Improvements continue to be made to the care planning process. Medication is managed safely and people have access to healthcare support as necessary. Staff treat people with respect. Peoples’ care needs are not always attended to in a timely manner or in a way that upholds peoples’ dignity. EVIDENCE: The home continues to update and improve the care planning process. At the time of this visit a new care planning system was in the process of being introduced. Some peoples’ files had been transferred to the new format and others were in the process of being transferred. Examples of both types of care plans were examined during the visit to the home. Those seen gave a clear description of the level of need and assistance that people required with their daily care needs. The home has identified key workers and named nurses for every person living at the home and it is their role to review the care plans on a monthly basis or earlier if required. Care Northlands House Nursing Home DS0000064233.V343029.R02.S.doc Version 5.2 Page 11 plans seen had been reviewed regularly. Care plans provided clear guidelines as to how staff should assist people with their care needs and what if any risks were present. Risk assessments had been completed as necessary and risk management plans were in place to address any identified risks. Records were available to demonstrate that people have access to a range of services such as GP’s, Dentists, Chiropodists and District nurses. Whilst these plans provided clear information non nursing staff spoken with had not read the plans. One person commented, that they had not read care plans, as they had not had the time to read them. They said that the work was allocated to them by nursing staff during the daily allocation meeting. Another care worker said that they had not been asked to read the care plans. In discussion with people living at the home their description of their personal care needs matched with the details recorded in the care plans. However the home needs to ensure that all staff involved in the delivery of care are familiar with peoples’ needs and this would include access to care plans. Result from surveys completed by people living at the home were as follows; two out of eleven people responded that they always received the care and support that they needed, seven said that they usually did, one answered sometimes and one responded that they never did. Comments received included, “ We know the staff are always busy and it is not always possible to get up and go to bed as desired”, “The care (name of resident removed to protect anonymity) gets is very good. I have no complaint about it although they are short staffed”, “Sometimes I am left on the toilet too long”, “ I sometimes have to wait a long time after pressing the buzzer, for very urgent things like toiletries. This is not the fault of the staff, but lack of them”. Another person commented, “The carers are short staffed and so often showers cannot be taken or taken out into the garden”. A relative commented “ My mother needs to be hoisted and there’s not always the staff and or equipment available when needed. If she needs the toilet she can be left waiting a considerable time sometimes. This week she was hoisted from bed to chair at 6 am and had to wait until 8 am before she was given a coffee and dressed”. Similar views to these were expressed during the meeting with a group of people and through individual discussions. This is commented on in more detail in the ‘Staffing’ section of this report. The medication administration records were checked for three people during the site visit. These represented one person from each floor of the home. From examination of these records it was evident that staff were following correct administration recording procedures and medication was stored safely and correctly. The home has treatment room situated on each floor. Each room had a dedicated secure fridge for storage of medicines and temperatures had been monitored regularly. All medicines were kept in secure trolleys and the only staff to have access to any medicines are the trained nursing staff. Northlands House Nursing Home DS0000064233.V343029.R02.S.doc Version 5.2 Page 12 All three peoples’ medication records were checked against stock held and all were found to tally. Records of controlled medicines administered and held within the home were checked. These were found to be stored and administered as per the homes’ policy and within regulations. People spoken with during the course of this inspection said that they felt that their privacy was respected. All bedrooms are single occupancy with en-suite shower facilities. There is a lockable storage facility in all rooms and space for people to meet with visitors in private. People were in agreement that staff respected their privacy, that they knocked on doors before entering and that male carers respected the dignity and privacy of female residents when assisting with personal care needs. However the length of time that people can wait to receive support with their personal care needs such as toileting means that at times their dignity is compromised. One staff member said that it was difficult to provide care when short staffed. They gave an example that if five people were incontinent they could not deal with them all at once. They also said that if they were short staffed in the morning then people had to wait longer to be assisted with washing and dressing. Another staff member said that sometimes they were short staffed and that this meant that people could not get up at their normal time. Northlands House Nursing Home DS0000064233.V343029.R02.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People who use 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. People living at this home can receive visitors as often as they please and keep in touch with their family and friends. People are free to make their own decisions and choices and receive a healthy diet. EVIDENCE: The home provides a range of different organised activities and people can choose whether or not to join in with these. This was confirmed through discussion with people living at the home. The home employs three activity coordinators and one was present the day of the visit. Whilst it was clear that people valued the input of the activities coordinator at the time of this visit the other two coordinators had been on long-term leave and this meant that other staff were having to help out wherever possible. Two out of the eleven people whom completed a questionnaire responded that the home always provided activities that they could take part in, five answered usually, three sometimes and one never. Comments included; “They are available, but I don’t want to join in”. “ There are plenty of activities, but I do not go to them all”. In discussion one person commented that many of the activities were not suitable Northlands House Nursing Home DS0000064233.V343029.R02.S.doc Version 5.2 Page 14 for people with visual or hearing impairments. One staff member said that whether or not they could spend one to one time with people was dependant on staffing levels. People observed and those spoken with told the inspector that they were free to spend their time as they chose and that there were not any restrictions imposed upon them and that they could pursue their own interests. People were in agreement that they could receive visitors as often as they wished and that there were not any restrictions on this and that visitors were made to feel welcome. This was reiterated by visitors. Generally people reported that they were happy with the standard of food that the home provides. During a group meeting of twelve people there was a general consensus of opinion that the quantity and choice of food was good. Three out of twelve people who completed a questionnaire responded that they always liked the meals, eight people answered usually and one person responded sometimes. Comments included; “Very much so they are excellent”, “Excellent” and “The meals are often cold”. Several people commented that the food was often cold. During discussion people said that meal times could take a long time. People had different opinions about whether the food was served hot or cold. This was discussed with the chef who explained that people had complained about food temperatures and as a result the home had recently installed new hot trolleys. The chef was of the opinion that since the introduction of these trolleys food was being served hot. The inspector saw that the temperature of cooked foods was being monitored and recorded at source and again before being served. The chef agreed that he would continue to monitor this. Evidence from a recent residents’ meeting held in July suggested that people felt the food was hotter now. Samples of menus were seen to evidence that people were offered a varied, healthy and balanced diet. The inspector was able to visit the kitchen and a selection of records were seen to demonstrate that infection control procedures were being followed that included, kitchen cleaning schedules, monitoring of fridges and freezers temperatures and food hygiene in general. Northlands House Nursing Home DS0000064233.V343029.R02.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use 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. People who live at this home need more information to enable them to make a complaint or raise concerns if necessary. At present the home cannot demonstrate that peoples concerns are dealt with appropriately. Systems are in place to protect people from harm or abuse. However people could be further protected. EVIDENCE: The home has a clear written complaints procedure and this is on display in the home. However results of questionnaires completed by people living at the home showed that just under, 50 of them knew how to make a complaint. Where as most of the relatives who responded said that they did know how to make a complaint During a group discussion the consensus of opinion was that people did not feel that their complaints were dealt with in a timely manner or that they were taken seriously and that they did not always receive a response. In discussion with one person they commented, “ If you tell someone a concern, it is the last that you hear of it”. The self-assessment document completed by the manager prior to the visit stated that the home had received three complaints in the last twelve months. However from examination of the homes’ complaints log there were five Northlands House Nursing Home DS0000064233.V343029.R02.S.doc Version 5.2 Page 16 entries of complaints being logged by the home since the last inspection up until the date that the manager completed the self-assessment. Equally the Commission for Social Care Inspection had received a complaint from someone living at the home in February 2007. There was not any record of this in the home’s complaints log or any evidence that the complaint had been dealt with. Neither was there any reference to it in the monthly report that is required to be carried out by the home under regulation 26 of the Care Homes Regulations 2001. The home has an adult protection policy, which guides the procedure should there be allegations of abuse. At the time of this inspection a serious allegation was being investigated by the local authority in respect of an allegation of abuse at the home and the Commission for Social Care Inspection had also received information that been referred to social services in respect of further allegations. In discussion with relatives some reported that security measures at the home were lacking out of office hours. People reported that they had discussed this but improvements had not been made. It was noted from discussion with people living at the home they none of them hold a key to their room. Although they are lockable from the inside people could not secure them when not in their rooms. The inspector could not find any reason or evidence as to why people are not provided or offered a key to their rooms. Staff receive training in abuse awareness during their induction training and this was confirmed through examination of staff records and in discussion with individual members of staff. Northlands House Nursing Home DS0000064233.V343029.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24 and 26 People who use 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. The physical environment is maintained and furnished to a good standard. The home is clean and tidy with sufficient procedures and systems in place to minimise the risk of cross infection. EVIDENCE: During the visit to the home the inspector saw all communal areas and a selection of bedrooms were viewed on each of the three floors. The home was clean throughout and there were not any adverse odours present. People living at the home were in agreement that the home is kept clean. Comments from questionnaires included, “Wonderfully clean” and “Excellent”. All bedrooms seen were comfortable and had been personalised with the person’s own furniture and or belongings reflecting each persons’ individuality and interests. Bedrooms had been fitted with appropriate aids such as call bells. Phone sockets are fitted in each room should someone wish to install Northlands House Nursing Home DS0000064233.V343029.R02.S.doc Version 5.2 Page 18 their own line. Each bedroom has an ensuite and individual heating controls so that everyone can have room their heated to their own preference or needs. There is a large lounge situated on each floor and smaller lounges that provide space for people to meet visitors in private other than own bedrooms. The home had recently installed two additional dishwashers on the ground and middle floor. Toilets and bathrooms were all found to be clean. It was reported that the majority of people use their own bathing/showering facilities in their rooms. Infection control procedures were observed to be in place. Liquid soap and paper towels were in place in all communal bathrooms and toilets. Supplies of gloves and aprons were available and staff were observed to use them. The home employs permanent cleaners and laundry staff. The inspector visited the laundry facilities and spoke with the staff. All clothing was labelled and appropriate washing facilities were installed and procedures were in place to deal with soiled linen and thus maintain infection control. At the last inspection a requirement had been made that the grounds surrounding the home must be made tidy, attractive and safe for people. The inspector found that this had been actioned and the external grounds were maintained, with plenty of seating areas, paths and ramps suitable for wheelchair access. Northlands House Nursing Home DS0000064233.V343029.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are caring and helpful. They are well trained and undergo a thorough recruitment process. However staffing levels do not meet the current needs of people living at the home and this is putting individuals at risk. EVIDENCE: In the self assessment document completed by the manager prior to the inspection it was stated that, “We maintain the correct numbers of staff agreed with the inspectorate and taking account of the individual needs of the residents”. However evidence gathered from this inspection would strongly suggest that they are not always sufficient staff to meet the needs of those living at the home. Evidence detailed in the ‘Health and Personal Care’ section of this report provide several examples of this such as staff commenting that they had not had the time to read care plans. People reporting that they have to wait a long time to receive personal care, to get up bed and go to bed and being left on the toilet for long periods. In discussion with staff they stated that they were often short staffed and that the effect of this was that people did not receive the care that they required in a timely manner. Responses to questionnaires completed by people living at the home were as follows; two out of twelve people said that staff were always available when they needed them, six said that they usually were and four people responded that they sometimes were. Northlands House Nursing Home DS0000064233.V343029.R02.S.doc Version 5.2 Page 20 Comments from questionnaires were “ The staff are wonderful but have a massive workload”. “ Short staffed so often not available”, “ Very often there is no conversation, excuse is there is not enough time”, ” Sometimes there could be a faster response” and “ Not enough staff, the nurses are short of time and therefore always short of time when it comes to washing and dressing”. Several relatives also commented that they felt the home was short staffed. During a group discussion with people living at the home there was a consensus from everyone at the meeting that the home was understaffed. People gave examples of having to wait excessively long periods for their call bells to be answered. People said that this could take as long as half an hour. They also said that they could wait a long time to go to bed. One person said that the time that they are assisted to get up can vary and that often this meant that she got up later than she wished. People also commented that there were a lot of staff changes. Records of residents meetings showed that the issue of staffing had been raised with the manager. The inspector saw that the manager had been keeping a record of the time taken for staff to answer call bells. From the records it was clear that people do at times have to wait for a long time before someone responds to their call. Staff said that staffing levels determine the length of time it can take to assist people to get up dressed and washed in the morning. From examination of the staff rota the inspector found that one floor was operating with one less staff member than had been planned for. Similar findings to these were reported on at the last inspection and a requirement was made. The recruitment records of four members of staff who had been employed by the home since the last inspection were examined. These demonstrated that the home follows procedures and carries out all relevant checks on staff prior to recruitment. Staff also receive induction training that covers relevant health and safety issues and addresses core areas such as moving and handling, fire, COSHH, food hygiene, health and safety and abuse training. During this period they are supplied with workbooks and induction packs with a range of policies and procedures for them to familiarise. Northlands House Nursing Home DS0000064233.V343029.R02.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 People who use 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. The management practices of the service fail to meet all the needs of those living at the home especially in relation to staffing levels, safeguarding and staff supervision. Health and safety is promoted within the home. Although the home has quality assurance policies action is not always taken to improve the service and not all statutory requirements are completed within agreed timescales. EVIDENCE: The registered manager has a number of years experience within the NHS. She has been in post at this home since 2005 and has completed the Registered Managers Award. The manager was on leave on the day of the visit. A senior nurse had been delegated the responsibility for the day-to-day running of the home in the Northlands House Nursing Home DS0000064233.V343029.R02.S.doc Version 5.2 Page 22 managers’ absence. Back up and support had been arranged and was being provided by senior management within BUPA. The senior nurse had received a handover from the manager and said that she felt that this had been sufficient to meet the day-to-day needs of the home. Until recently the home had employed a deputy manager and at the time of this visit this post was vacant. The nurse also had to attend to care duties such as administering medicines and therefore had duties to attend to on top of the management of the home. The senior nurse had access to all files and information to enable the inspector to carry out a full inspection of all key standards and assisted the inspector throughout the inspection. Whilst some requirements had been met from the previous inspection, not all had been. BUPA has a quality assurance system in place and personnel from head office regularly undertake audits. People living at the home generally felt that they did not have a say in the running of the home or that their opinions were listened to. One person used the term, “Lip service”. None were aware of previous inspection reports. People said that resident meetings were held. Relatives felt that these were over attended by staff and people did not think that anything changed as a result. Staff said that they considered that they received enough support to carry out their roles. However none of the staff spoken with had received any formal supervision and no records were available to show that this had taken place. On arrival at the home maintenance staff were on the premises carrying out checks of fire detection equipment and the alarms system. The home has maintenance staff on site every day. Examination of the fire logbook demonstrated that regular and thorough testing of the home’s fire detection and fire-fighting equipment was being carried out. Certificates and service contracts were seen and the inspector was satisfied that all equipment used within the home had been regularly checked and serviced. There were not any concerns with regard to safety within the home environment and staff undertake regular fire training. Northlands House Nursing Home DS0000064233.V343029.R02.S.doc Version 5.2 Page 23 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 1 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 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 1 17 X 18 2 3 X X X X 3 X 3 STAFFING Standard No Score 27 1 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 1 X 3 Northlands House Nursing Home DS0000064233.V343029.R02.S.doc Version 5.2 Page 24 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 OP2 Regulation 5(1)(b) Requirement You are required to ensure that every service user admitted to the home is issued with a terms and conditions of residency to include the room that is to be occupied and the amount and breakdown of fees. Previous timescale of 31/08/06 not met. You must ensure that people are not left waiting for long periods to use the toilet or to be assisted with their personal care needs. A record must be kept of all complaints received by the home and any action taken. You must provide people with the means to protect their belongings and take measures to minimise the risk of people entering the home without permission. The registered manager must ensure that there are sufficient numbers of staff on duty over the twenty-four hour period to ensure that service users needs are met in a timely fashion. Timescale for action 01/11/07 2 OP10 12(4)(a) 01/11/07 3 4 OP16 OP18 17(2) Schedule 4 (11) 12(1)(a) 01/11/07 01/11/07 5 OP27 18(1)(a) 01/11/07 Northlands House Nursing Home DS0000064233.V343029.R02.S.doc Version 5.2 Page 25 6 OP36 18 (2) Staffing rotas must be reviewed on a regular basis to correlate with the dependency of the service users in residence. Previous timescale of 30/09/06 not met. A system of formal supervision must be introduced for care staff. 01/11/07 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 OP7 Good Practice Recommendations It is recommended that all staff have access to the care plans. Northlands House Nursing Home DS0000064233.V343029.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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.V343029.R02.S.doc Version 5.2 Page 27 - 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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