Inspection on 01/05/07 for Summer Lodge

This inspection was carried out on 1st May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Summer Lodge 20/11/08

Summer Lodge 29/05/08

Summer Lodge 30/11/07

Summer Lodge 19/04/06

Summer Lodge 28/11/05

Summer Lodge 23/06/05

Summer Lodge 14/12/04

Summer Lodge 09/06/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sackville Nursing Home 2 - 4 Sackville Road Hove East Sussex BN3 3FA Lead Inspector Jennie Williams Key Unannounced Inspection 01 May 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 Sackville Nursing Home DS0000014051.V335702.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. Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sackville Nursing Home Address 2 - 4 Sackville Road Hove East Sussex BN3 3FA 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) 01273-775577 sackville@vigcare.com Mr Joginder Singh Vig Mrs Beant Kaur Vig Post Vacant Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users must be older people aged sixty-five (65) years or over on admission. The maximum number of service users to be accommodated is twenty-eight (28). To admit one service user with a dementia type illness Date of last inspection 25th October 2006 Brief Description of the Service: Sackville Nursing Home is a care home registered for twenty-eight (28) places for residents, of either gender, aged sixty-five (65) or over. Nursing care is provided at the home. The Registered Providers own several care homes throughout the South of England, predominantly older people services. The home is located in a residential area of Hove. There are local amenities in the area and there is nearby access to public transport. There is no parking available at the home and restricted paid parking at adjacent streets. There are twelve (12) rooms for single occupancy, of which five (5) have en suite facilities. There are eight (8) double rooms, of which one is provided with en suite facilities. Rooms are located over three floors. There is a passenger shaft lift that assists residents to access all areas of the home. There is a lounge/dining area on the ground floor. There is a garden at the rear of the building that is accessible to residents. There are suitable numbers of toilet and bathing facilities located throughout the home to meet the needs of residents. Fees range from £471.90 to £580 per week. Additional fees are: hairdresser (£7 to £15), chiropody (£7), toiletries and newspapers/magazines (at cost). This information was provided to the CSCI on the 14 May 2007. Prospective residents find out about the service through social services, living in the area and word of mouth. Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. It should be noted that following recent CSCI consultation, it was identified that service users prefer to be called people who use services. The manager confirmed that they use the term service users/residents. For the purpose of this report, people who use the service will be referred to as residents. This unannounced key inspection took place over eight hours on the 1st May 2007. Twelve residents were spoken with throughout the inspection process. The Inspector had limited communication with some residents. Two residents did not wish to speak with the Inspector and this was respected. 10 resident surveys were taken to inspection, of which two residents chose to complete. Two care plans were viewed and specific areas of care were looked at in a further five care plans. The manager, three registered nurses and three care staff were spoken with during the inspection process. Three staff files were viewed and training records inspected. A visitor was spoken with on the day of the inspection. A tour of the environment was provided and some individual rooms were viewed, with the resident’s permission. Medication procedures were inspected. The quality assurance system was discussed and complaint and Safeguarding Adult procedures were viewed. Copies of the staff rota and menus were viewed. Health and safety records were not viewed as this information was viewed during the registration process. There were twenty-four residents residing at the home on the day of the inspection. What the service does well: The home has information available for prospective residents/representatives on the facilities and services provided to make an informed decision if their needs can be met at the home. The pre admission process ensures that only residents whose needs can be met at the home are admitted. Care plans are in place to provide guidance on the nursing needs of individuals. Medication Administration Record (MAR) charts viewed demonstrated that medicines were being signed for at the time of administration. Residents spoken with stated that they were happy with the care provided at the home. Routines of daily living are generally to the individual’s choice and preference. It was observed during the inspection that visitors were warmly welcomed when visiting the home. Residents confirmed that staff respect their privacy and dignity. Staff were observed to have a good professional rapport with Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 6 residents and were heard to be calling them by the preferred term. Activities are provided at the home that are within an individuals choice and ability. Residents found their rooms to be comfortable and the home was clean and communal areas free from offensive odours. There are currently suitable numbers of staff on duty and service users are safeguarded by the recruitment procedures in place. The quality assurance and quality monitoring system being developed will ensure that the home is run in the best interest of service users. What has improved since the last inspection? What they could do better: Care plans and information in use regarding the care of residents need to be consistent, current and reviewed with the individual/representative to ensure that choice and preferences are reflected. It is required that nutritional assessments are undertaken on admission and periodically for all residents to ensure nutritional needs are being met and appropriate action can be taken when problems are identified. Risk assessments undertaken on daily living activities need to be expanded to provide guidance for staff on how to reduce the risk, ensuring the safety of the Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 7 resident. Residents must be offered an opportunity to self-medicate based on a risk assessment to ensure that independence is encouraged and maintained as much as possible. Urgent action is required to ensure that controlled drugs are recorded and disposed of correctly and that excess controlled drugs are not stored at the home. This will promote the safety for service users and staff. A meeting was held with the Registered Provider in February 2007 regarding the high number of concerns raised and the appropriateness of responses and the importance of monitoring and auditing concerns and complaints. It will assist the manager and Registered Provider if complaint information regarding the home was held at one location. Clear information needs to be available for inspection on the number of complaints received about the home and the action taken to resolve these, to evidence that the home deals with these appropriately. The Safeguarding Adults procedure must be amended to reflect current guidelines and provide clear guidance for staff to follow in the event of an allegation of abuse being made. It remains an outstanding requirement that the Registered Provider prepares a programme of refurbishment for the home, which relates to redecoration, repair and replacement of carpets, curtains and bed linen within a reasonable timescale to ensure service users remain living in a well-maintained and homely environment. Action is required to ensure that staff receive structured induction and foundation training to ensure the aims and objectives of the home are met. The Registered Providers must ensure that an appointed manager is fit to manage the service and meets the legislative requirements for this role. Priority must be given to ensure an application is forwarded to the CSCI to begin the registration process for a manager. It remains an outstanding requirement that the Registered Provider undertakes Regulation 26 visits and prepares a report for the manager, to ensure they are made aware as the responsible person that the service is meeting its legislative requirements. A copy of these reports are required to be forwarded to the CSCI. Other minor shortfalls noted, which have not been reflected as a requirement or recommendation have been noted throughout the inspection report. Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 8 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. Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 & 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has information available for prospective residents/representatives on the facilities and services provided to make an informed decision if their needs can be met at the home. The pre admission process ensures that only residents whose needs can be met at the home are admitted. EVIDENCE: The manager confirmed that the Statement of Purpose and Service Users Guide is currently being updated. A copy of the most recent Service Users Guide was provided to the Inspector. This provides information on the facilities and services provided at the home. The manager confirmed that she takes a copy of these documents when assessing any prospective resident. The pre admission assessment viewed demonstrated that the needs of the individual can be met. The manager or a registered nurse will undertake the Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 11 pre admission assessments of any prospective resident. The manager confirmed that an admissions checklist has been developed and implemented. This is currently with head office of the company for approval. The manager confirmed that there was no one residing at the home from any minor ethnic community, social/cultural or religious groups with any specific needs or preferences. One resident had limited English communication, however staff are familiar with this persons communication methods and family members are involved in assisting the home to communicate when medical attention is required. Of the residents that were asked, all confirmed that they felt their needs were being met at the home. Some residents spoken with confirmed that they had visited the home prior to moving in. A visitor spoken with confirmed that they visited the home prior to their friend/relative being admitted. The manager confirmed that prospective residents are encouraged to visit the home before moving in. The home does not have dedicated accommodation to provide intermediate care. Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Recent professional input ensures healthcare needs are being met, however care plans in place need to be consistent in information and reflect individuals’ choice and preferences. Residents are not offered an opportunity to maintain independence in relation to controlling their own medicines. EVIDENCE: Care plans were not thoroughly inspected on this occasion as no shortfalls had been noted at the last inspection. Two care plans viewed did not provide clear information to the reader on the individual’s preferred daily routines. There was information provided as guidance to staff on how to meet the nursing needs of the individual. There was evidence that most care plans are being reviewed on a monthly basis, however one had not been reviewed for the month of April. It was Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 13 evident that not all sections of the care plans were being reviewed and one contained information that was no longer prevalent to an individual. There was evidence that the individual or representative was involved in the initial drawing up of the care plan, however no evidence was seen to identify if they are involved in the reviewing process. Some residents and a visitor spoken with confirmed that staff discuss their care with them, however are not familiar with the care plans. The information provided to the Inspector regarding the reviewing process was conflicting. A registered nurse confirmed that she reviews the care plans with the residents, however the manager confirmed that they are not reviewed with the individual/representatives. The manager has recently implemented a form to monitor care plans on a monthly basis to ensure they contain accurate information and are being regularly reviewed. Staff had implemented a brief overview of individual’s activities of daily living. This information was recorded in two different areas and provided different information in some areas of care. One residents care plan identified that an individual required input from a chiropodist. The last date recorded for this visit was January 2005. The manager confirmed that a chiropodist last saw this resident in March 2007. The reader would have had to read through numerous documentation to ascertain all the dates the chiropodist attended to the individual. A form has been implemented to clearly identify when a health professional has visited an individual, staff must be reminded to complete this form. It was noted that there were no nutritional assessments being undertaken. The manager confirmed that assessments are undertaken on those residents where there are concerns regarding their weight/nutritional well being. She confirmed that residents are weighed at the time of admission and then weighed monthly. Following previous concerns/allegations raised with the home, the home has received professional input from various health professionals including a diabetic nurse and tissue viability nurse and nurse specialist etc. Prior to this, healthcare appeared reactive rather than proactive. Risk assessments were noted to be in place. Some areas of daily activities identified the rating of risk to an individual, however did not provide any guidance to staff on how to reduce the risks. There are no specific risk assessments in place for bed rails, however the home has implemented written assessments of why they are needed. One consent form was noted not to have been signed by the individual/representative. This is not reflected as an outstanding requirement as the manager confirmed that she would ensure they are all signed. Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 14 The procedures for medications were viewed with a registered nurse. It was confirmed that there are policies and procedures in place for all aspects of dealing with medication. The content of these were not read. Medication Administration Record (MAR) charts viewed demonstrated that medicines were being signed for at the time of administration. It was concerning to note that there were controlled drugs being stored at the home for six residents who had either died or left the home. Records viewed demonstrated that one resident died in November 2005 and the controlled drugs had been recorded as no longer being at the home in January 2006. This medicine was found to still be in the cupboard. Some controlled drugs being stored were not clearly identifiable in the register and the Inspector had to look through all the pages of the controlled drug book before being able to locate the correct page. The manager stated that she has not offered anybody the opportunity to maintain control of their own medicines and no one had enquired about this. She confirmed that with the residents currently residing at the home there was no one who would want to or could manage their own medications. Of the residents that were asked, all confirmed that staff respect their privacy and dignity. Staff were observed to have a good professional rapport with residents and were heard to be calling them by the preferred term. Most residents confirmed that staff knock on their room doors prior to entering. Staff must be reminded regarding the terminology used in an individuals care plan. For one resident who required assistance at meal times someone had written, ‘She is a feeder’. This terminology used is not professional and does not promote person centred care or maintain dignity for that person. This has not been reflected as a requirement but management must ensure that staff use appropriate terminology. Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ lifestyle within the home is not always their choice. Residents are provided with sufficient stimulation to fulfil their interests and needs. The provision of meals within the home is gradually improving to ensure preferences and nutritional value is catered for. EVIDENCE: Most residents spoken with confirmed that the routines of daily living were flexible and their own choice. One resident survey demonstrated that assistance with a bath or shower is not always when they choose. One resident commented to the Inspector that they have been woken up at 7.00am for the past few weeks when they would have preferred a lie in. The Inspector was concerned when viewing the minutes of the last staff meeting it was written, ‘Bedtime 6.30 for clients to go to bed, unless a client asks to go earlier unless there is a medical concern….’. The manager had left the inspection prior to the Inspector reading these notes, so was not able to Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 16 clarify the meaning of this statement. The manager must ensure that bed times and daily routines are within individual’s choices and preferences. There is an activity co-ordinator employed at the home for four hours on three days. An activity programme has been devised and ensures that those residents remaining in their rooms are provided with activities within their interest and abilities. Advertisements for upcoming events/entertainment were displayed in the lounge room. The majority of residents spoken with confirmed that there were enough activities provided at the home if the choose to be involved. One resident survey demonstrated that sometimes there are activities arranged by the home that they can take part in. It was observed during the inspection that visitors were warmly welcomed when visiting the home. A visitor spoken with confirmed that there are no restrictions on visiting and is made to feel welcomed. There were mixed feelings regarding the provision of meals. The majority of residents were complimentary about the food and confirmed that there is generally a choice in meals. Comments ranged from ‘alright’ to ‘very good’. The menu viewed demonstrated that a variety of meals are provided. One written comment received about the food was ‘generally rather good. Pasta at supper can be boring, ditto endless carrots. Would love to shake hands with, say, a broad bean.’ The cook confirmed that his food and hygiene training is up to date and there is information available regarding the dietary preferences of individuals. The manager confirmed that ten care staff have undertaken food and hygiene training and it is proposed that all staff will receive this training. There have been previous concerns relating to the provision of supper meals. The manager confirmed that a new supper menu has been implemented and monitoring being undertaken. The process of serving meals has also been changed to ensure that all meals are kept warm until the resident is ready to eat. This has not been reflected as an outstanding requirement as there is evidence that work is being done to address this shortfall. It has been previously recommended that the cook undertakes a course in the role of nutrition in ensuring the health of older people. This had been arranged, however the training fell through. This has not been reflected again as a recommendation, however the providers should continue to ensure this training is accessed. The home has purchased a manual that provides guidance on planning menus. The cook confirmed that fresh fruit, vegetable and meat are delivered to the home at least weekly. Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Most residents feel comfortable to make a complaint, however these are not always dealt with appropriately. There has been a significant number of Safeguarding Adult investigations and with staff and management not being proactive at reporting incidents, places further residents at additional risk. EVIDENCE: It was difficult to assess exactly how many complaints had been raised with the home due to all information not being kept at the home. The Registered Providers had recently provided the manager with a chronology of allegations and complaints made regarding the home. On discussion with the manager, she confirmed that the Registered Providers discussed complaints with her, however did not share the correspondence with her on occasions and she was not aware of the outcomes of some of the complaints. A meeting was held with the Registered Provider in February 2007 regarding the high number of concerns raised and the appropriateness of responses and the importance of monitoring and auditing concerns and complaints. Information available showed four complaints have been made to the home since the last inspection, of which one of these resulted in a Safeguarding Adult referral being made and being dealt with through these procedures. Two Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 18 complaints were substantiated and one is unresolved and ongoing. The manager confirmed that action has been taken to address any shortfalls identified from these complaints. One complainant has not been happy with the way the home has dealt with their complaint. A visitor spoken with confirmed that they know who to speak to if they had to raise any concerns and would feel comfortable to do so. Of the residents that were asked, most confirmed that they would feel comfortable to make a complaint. One resident survey identified that they know how to make a complaint and the other survey identified that they were refer their complaint to their relative. There have been six Safeguarding Adult investigations made since the last inspection. Five of these were substantiated following investigation. The majority of the alerts were made from other health professionals concerned regarding the standards and care within the home. One referral was made by CSCI following receipt of an incident report sent by the home. It was concerning to note that the manager or staff had not noted the early signs of concerns raised and taken appropriate action themselves prior to incidents becoming Safeguarding Adult alerts. It has been an outstanding requirement that staff attend Safeguarding Adult training. The manager confirmed that all but three staff have attended this training. Two of the staff spoken with confirmed that they have attended Safeguarding Adult training. The Safeguarding Adults procedure needs to be updated to provide clear guidance to staff on the procedures to follow in the event of an allegation being made. The information contained in the policy read did not provide any information that all allegations of abuse must be referred to Social Services, as they are the lead authority in these investigations. It also referred that if the investigation results in prosecution and conviction of staff member, this result must be communicated in writing to the National Care Standards Commissions (NCSC) for consideration of inclusion in the Protection of Vulnerable Adults (POVA) register. This is not a role for the CSCI to undertake but is the responsibility of the Registered Provider/Registered Manager. Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are provided with suitable facilities. Further redecorating and refurbishments are needed within the home ensure residents reside in a wellmaintained environment. EVIDENCE: The home is an old building and areas within the home are in need of redecoration. The provider has been required to provide the CSCI with a programme for refurbishment for a period of time and one still has not been received. The manager confirmed that some carpets have been replaced and rooms are being redecorated as they become vacant. Further work is required. The manager confirmed that one had been devised and understood that it had been sent to CSCI. This has not been received. Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 20 Of the residents that were asked, all confirmed that they were happy with their rooms and the beds were comfortable. The manager confirmed that bed linen has been changed and there is currently an order in for new bed covers and pillowcases. It was noted when viewing residents’ rooms; some beds were in need of new covers and some pillows had no covers on them. Concerns had been previously raised that call bells were not left within reach for residents to use. On the day of the inspection call bells were noted to be left within reach of individuals. Following the undertook an The manager this would be result of a Safeguarding Adult referral, a tissue viability nurse audit of suitability of the bed mattresses provided at the home. confirmed that there remained three mattresses to replace and completed within the next couple of weeks. On a tour of the home, it was observed that some televisions were static and the picture not clear to see. A representative for the providers confirmed that the aerial had recently been fixed and no one had reported any problems. It was confirmed that this would be looked at again. Other minor shortfalls were provided to the representative during feedback for the home to address. Some areas to be considered were; the cleaning of the extractor fans in en suites, excess storage of pads in bathrooms and one room that was noted to be offensive on the day of the inspection and ensuring the underneath side of shower chairs remain clean. It was also noted that the location of a toilet roll holder in a communal bathroom was located on the other side of a sink from the toilet, possibly limiting individuals’ independence when using the toilet. One communal bathroom had glass in the door with just a thin lace curtain covering this. This raised the query if this promotes an individuals dignity at night when the light is on. The home must ensure the curtain is sufficient to provide screening. The communal areas were observed to be free from offensive odours on the day of the inspection. Sluice facilities are provided throughout the home. Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met with the number of staff of duty and are safeguarded with the recruitment procedures. Staff and residents are placed at risk due to no structured induction and foundation training being provided to new staff. EVIDENCE: Staff spoken with confirmed that they enjoyed working at the home. Staff and residents spoken with confirmed that there is sufficient staff on duty. Staff were observed to have a good professional rapport with service users. Comments about the staff ranged from ‘not to bad’, ‘very helpful’ to ‘excellent’. There are eleven care staff employed at the home. The manager confirmed that five staff have completed National Vocation Qualification (NVQ) level 2, five are currently undertaking these studies and one is to be enrolled on the course. Staff files viewed identified that all recruitment checks are undertaken for staff. References are obtained, along with an application form and an enhanced Criminal Record Bureau (CRB) undertaken for all staff, including Protection of Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 22 Vulnerable Adults (POVA) checks. Personal Identification Numbers (PIN) are also checked for registered nurses to ensure they have current registration with the Nursing and Midwifery Council (NMC). Staff spoken with confirmed that they have received a job description and contract and felt that the recruitment procedures were done fairly. Staff spoken with confirmed that they are kept up to date with mandatory training and are provided with additional training opportunities relevant to their roles. The registered nurses confirmed that they receive training relevant to their responsibilities. Staff confirmed that some recent training undertaken are: first aid, syringe drivers, food and hygiene and pain control etc. A nurse specialist had been providing support to the home and training to staff on the basics of personal care, falls and record keeping. It was noted that there was no structured induction or foundation training for new staff. Some staff have received in house induction. The manager confirmed that she has received information a few weeks ago regarding the Common Induction Standards. The new Common Induction Standards came into force in October 2006 and the home should have already implemented these. When providing feedback to the representative for the Registered Providers it was confirmed that the home did have induction packs that had been confirmed by a company as complying with the new guidelines and that these should have been implemented at the commencement of employment for individuals. Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 & 38 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is generally run in the best interest of residents, however a more structured quality monitoring system would enable management to monitor the success of the home in meeting its aims and objectives. The health, safety and welfare of residents and staff could be better promoted and protected. EVIDENCE: The home has been without a Registered Manager since approximately June 2005 and priority must be given to ensure an application is forwarded to the CSCI to begin the registration process for a manager. The Registered Providers must ensure that an appointed manager is fit to manage the service and meets the legislative requirements for this role. Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 24 The manager, appointed by the Registered Provider, has been working at Sackville Nursing Home since July 2005. She is a registered nurse with current registration with the Nursing and Midwifery Council (NMC). She has worked in a variety of settings in various positions. She confirmed that she commenced the Registered Manager Award course in December 2006. Staff spoken with confirmed that they find the manager approachable and supportive. Conflicting information was provided to the Inspector as to the number of managerial days provided to the manager. It is recommended that the rota be amended to reflect when the manager is working with the residents or on a managerial day. The manager confirmed that she proposes to undertake quality-monitoring surveys every six months. She confirmed that resident surveys are due to be done again. It has been over one year since any quality monitoring has been undertaken. The manager confirmed that questionnaires would be sent out to stakeholders, residents and relatives/visitors. She has implemented forms to monitor the cleanliness of the home weekly and monthly audits of the care plans. Following outstanding requirements made regarding the presentation of meals and provisions of supper, the manager has commenced monitoring these meals and obtaining feedback from residents. She plans to analyse these results and take any action identified. Staff meetings are held monthly and it was confirmed that resident meetings do not take place. It is an outstanding requirement that the Registered Provider undertakes Regulation 26 visits and prepares a report for the manager, to ensure they are made aware as the responsible person that the service is meeting its legislative requirements. The expectations and content of these reports were discussed with the Registered Providers at a previous meeting with CSCI representatives. The last report located at the home was dated August 2006. The action plan received from the random unannounced inspection demonstrated that this will commence to take place in December and will be ongoing. The processes for handling residents’ monies were not assessed on this occasion. The manager had left inspection prior to the Inspector viewing the records. A registered nurse confirmed that when relatives/visitors receive money for an individual, this is kept securely at the home and a receipt is given to the relative/visitor. The last key inspection demonstrated that there were suitable procedures in place for the handling of residents’ finances. No health and safety records were checked at this inspection. The manager and maintenance person confirmed that all relevant checks are undertaken. The maintenance person confirmed that a test has just been sent off for Legionnaire disease. Temperatures of hot water taps are tested monthly and weekly tests are undertaken of the fire alarms. The maintenance person is currently waiting to undertake a health and safety course. Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 25 It has not been reflected as a requirement, however the Registered Providers must ensure that all staff understand and undertake fire drills. On speaking to staff, one confirmed that a fire drill was undertaken two months ago whilst others said a fire drill is undertaken every Friday. Records were not viewed, however staff need to be made aware of the difference of fire drills and fire alarm testing and the provider must ensure the practices are in compliance with fire regulatory guidelines. Sackville Nursing Home DS0000014051.V335702.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 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X X X X 2 Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1)&(2) & 12(2)&(3) Requirement That care plans and information in use regarding the care of service users is current and reviewed with the individual/representative to ensure that choice and preferences are reflected in relation to their care and daily routines. That nutritional assessments are undertaken on admission and periodically for all service users to ensure nutritional needs are being met and appropriate action can be taken proactively instead of reactively. That the risk assessments undertaken on the daily living activities are expanded and provide guidance for staff on how to reduce the risk, ensuring the safety of the service user. That service users are offered an opportunity to self-medicate based on a risk assessment to ensure that independence is encouraged and maintained as much as possible. That controlled drugs are DS0000014051.V335702.R01.S.doc Timescale for action 15/07/07 2. OP8 14(1)(a) & (2) 15/06/07 3. OP8 13(4) (b&c) 15/07/07 4. OP9 12(2)&(3) 31/05/07 5. OP9 13(2) 31/05/07 Page 28 Sackville Nursing Home Version 5.2 6. OP16 17(2) Schedule 4 (11) 7. OP18 13(6) 8. OP19 23 (2)(b) 9. OP30 18(1)(a) & (c)(i) 26 10. OP33 recorded and disposed of correctly and that excess controlled drugs are not stored at the home. This will promote the safety for service users and staff. That clear information is available for inspection on the number of complaints received about the home and the action taken to resolve these, to evidence that the home deals with these appropriately. That the Safeguarding Adults procedure is amended to reflect current guidelines and provide clear guidance for staff to follow in the event of an allegation of abuse being made. That the Registered Provider prepares a programme of refurbishment for the home which relates to redecoration, repair and replacement of carpets, curtains and bed linen within a reasonable timescale to ensure service users remain living in a well maintained and homely environment. This has been an outstanding requirement since 20.01.06. That all staff receive structured induction and foundation training to ensure the aims and objectives of the home are met. That the Registered Provider undertakes Regulation 26 visits and prepares a report for the manager, to ensure they are made aware as the responsible person that the service is meeting its legislative requirements. A copy of these reports are required to be forwarded to the CSCI. (Timescale 01.12.06 not met) 15/06/07 31/05/07 31/05/07 31/05/07 31/05/07 Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 29 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 OP27 Good Practice Recommendations That the rota is amended to reflect when the manager is working with the residents or on a managerial day to ensure that time is allocated for her to undertake management duties. Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Local 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 Sackville Nursing Home DS0000014051.V335702.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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