Inspection on 28/11/05 for Summer Lodge

This inspection was carried out on 28th November 2005.

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

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

Other inspections for this house

Summer Lodge 20/11/08

Summer Lodge 29/05/08

Summer Lodge 30/11/07

Summer Lodge 01/05/07

Summer Lodge 19/04/06

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 Elizabeth Dudley Announced Inspection 28th November 2005 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.V253152.R01.S.doc Version 5.0 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.V253152.R01.S.doc Version 5.0 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 Mr Joginder Singh Vig Mrs Beant Kaur Vig 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.V253152.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users should be 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 23rd June 2005 Brief Description of the Service: Sackville Nursing Home provides nursing care and accommodation for up to twenty-eight older people. The home is owned by Vig Care, who own four other care homes in East Sussex. The home is situated in Hove, and is close to the town centre and local transport links. Sackville is a detached residence with accommodation provided over three floors. Residents are able to access all areas of the home via a passenger lift. Accommodation is provided in twelve single and eight shared rooms. There is a lounge/dining area on the ground floor, with a garden at the rear that is accessible to service users. Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on the 28th November 2005, over a period of 8 ½ hours and was facilitated by the relief manager (referred to as ‘the manager’ in the body of the report) Mrs Linda Geraghty. During the course of the inspection, a tour of the home was undertaken, documentation, including personnel files, health and safety records and care plans were examined and 20 residents, 2 visitors and six members of staff were spoken with. What the service does well: What has improved since the last inspection? The relief manager, Mrs Geraghty has been in post for three months, and during this short time has addressed several issues including the standard of cleanliness and tidiness within the home. The garden area has also been tidied up and rubbish removed and alternative storage found for bicycles, therefore providing a more pleasant area for residents. Likewise the lounge area has been tidied and trolleys and unnecessary equipment removed. An activities person has now been employed to spend more time in the home and the variety of activities has been increased. Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 6 Care plans have been audited and improved, whilst policies are in the process of this. The manager is making efforts to ensure that all personnel files are compliant with the regulations and when interviewing staff for the home will ensure that they will be able to be understood by residents and will be able to respond to their needs. It is expected that improvements made in the home will be enduring. What they could do better: The home needs to ensure that all documentation used to inform residents about the home is in place and factually accurate. There are some maintenance issues within the home; the provider has been asked to supply the CSCI with a programme of redecoration, recarpeting and refurbishment detailing a reasonable time scale in which these can be expected to take place. The staff must be aware of the rights of the resident in regard to choice, about whether they sit at a dining table for meals, whether over bed tables are removed when they finish a meal, and the provision of a telephone that can be used by those who are nursed in bed. Choices now take place around meals but meals were found to be served lukewarm due to the size of the home and the fact that many residents have to take meals in their rooms. It was noted that there was no way to prevent beverages becoming stale or cold. This was also identified in the responses to questionnaires and by residents within the home. The menu offered at suppertime needs to be reviewed. Personnel files did not contain all the documentation required by regulation and this must be addressed. The home has complied with the majority of the requirements made at the last inspection and during a visit to the home. Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 7 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. Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5, No evidence was seen of appropriate documentation to aid residents on their choice of home. All residents are assessed prior to their admission to ensure the home can meet their needs. EVIDENCE: The statement of purpose for the home was not available to be seen on the day of inspection, the service users guide was seen, as was the brochure for the home. The manager was unsure as to whether service users have a copy of the service users guide, and this was not found in any rooms during the tour of the home. The manager has been advised that all service users must have a copy of this, and that both this and the statement of purpose must be taken when she assesses residents and also a copy of each should be left in a prominent position in the home, to be available for visitors or prospective residents. The brochure that is currently made available to prospective residents is factually inaccurate, stating that the home has a whirlpool bath, which is now removed, that volunteer visitors attend the home and that the home has a physiotherapist. The manager confirmed that this is not now so. Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 10 The manager was unsure whether residents were given a statement of terms and conditions on moving into the home and must ascertain this and ensure that this is happening. The manager assesses all residents prior to their being admitted to the home to ensure that the home can meet their needs. The appropriate documentation is in place and this forms the basis of the care plan. Prospective residents and their relatives can come and visit the home, and all residents are initially admitted to the home on a month’s trial period. Discussions with the manager took place relating to the need to ensure that only residents, whose physical nursing needs were a priority, are admitted to the home. Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10, Care plans identify the care to be given but require additional information to ensure that residents have full participation EVIDENCE: All residents have an individual care plan recording their physical, psychological and personal care needs. Of these care plans a sample of five were examined in depth. Of these the majority had been reviewed monthly, however in some instances some parts of the care plan were only being reviewed six monthly, particularly where there was no change or where the plan was for a specific area, i.e. skin care. This does not meet the standard and in this age group, change can be rapid and may go unnoticed. Staff must review each specific part of the care plan on a monthly basis. Care needs were clearly documented and staff are signing and dating the care plan when there is a change of need noted. There was evidence of GP, opticians and dentist’s visits and that other health care professionals had been consulted as required. In view of outdated pressure care equipment in one cupboard, it is Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 12 recommended that a request is made to the wound care nurse for a mattress audit, however some pressure relieving equipment in the home was in line with current practice. Care plans need to include consent forms and risk assessments for the use of bedrails, the signatures of the resident or representative to show that they are aware and in agreement to the proposed care to be given, risk assessments to show capacity for the holding of a room key and locked facility key, and the catheter batch numbers for any residents who are catheterised. The clinic room was clean and there was evidence of stock rotation. The manager is aware of the new disposal of drugs methodology and all medications had been signed following administration and on receipt and disposal. Eye drops require their date of opening written on them and the home must obtain an updated ‘British National Formulary’, or similar publication. All prescribed food supplements must be treated as a medication. Residents spoken with stated that they felt that their dignity was maintained and that treatment, including GP visits took place in their rooms. It was noted that residents sitting in the lounge were having their meals on over bed tables, following the meal these tables remained pushed up against the chairs making it difficult for residents to be able to move if they so wished. Screens are provided in double rooms and staff were seen to knock on doors prior to entering rooms and to address residents politely. Some residents felt that they could not understand what the staff were saying on occasions and one said that ‘they don’t know what I want, and I don’t know what they are saying’, whilst another stated ‘ It is so difficult for staff to understand me, and I do not hear well’. The manager must ensure that staff employed have a fair standard of English and must be able to understand the different intonations and pitch of voice used by the older person, particularly those with hearing or speech difficulties. Two of the questionnaires provided for visitors to the home commented on the quality of English of some of the staff. This is important when meeting the needs of the older person. All care staff spoken with on the day of inspection had a good quality of spoken English. Only three residents have their own telephone, other residents having to use the pay phone on the ground floor or take calls from the phone extension on the first floor or the main office. The home must consider other ways of ensuring residents privacy when they are making or receiving telephone calls. Although there were no residents that were very ill on this visit, the manager had training records to show that some staff have undertaken some study at the hospice and that one member of staff was undertaking an update course of Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 13 use of a syringe driver at this time. However some concerns have been raised in the past relating to staff appreciation of the needs of the very ill resident and their relatives, the manager is addressing this through further training. Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Activities are provided to residents by a specific person, but an activities programme must be displayed and made available to all residents in order that the quality of all those living in the home can be maintained. The menu is varied but the temperature of the food and the presentation of the trays need to be addressed to ensure that all residents enjoy their food and have a sufficient nutritional intake. EVIDENCE: The home is attended by an activities person, this has recently been increased to four times a week, and he provides activities including board games, videos of the ‘Pathe news’, reading newspapers and the provision of library books. A musical entertainer was visiting on this day and it was evident that this was very much enjoyed by residents. This must be continued. The activities person also takes residents shopping or out for walks. An activities programme must be provided and displayed where residents can see it, and residents social preferences and previous and past interests must be identified in the care plan. Records of residents who take part in specific activities are kept, but these are spasmodic, and the activities person must complete these at the end of every session. Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 15 There was no evidence that the activities person visits those residents who do not leave their rooms, but nevertheless may still require the provision of activities. Residents stated that they were able to choose their times of rising and retiring and that these choices extended to their other activities of daily living. As stated in National Minimum Standard 10, this should include the opportunity to eat at a dining room table rather than in their chairs and also that over bed tables should be removed from the restrictive position over the chairs and that all protective clothing must be removed when the meal is finished. It was noted that in several rooms, where residents were being nursed in bed, that televisions had been left on very loud, residents were unable to change programmes or to turn the television off should they so wish. This must be addressed. There is an open visiting policy but this must be displayed in the entrance hall in order to inform visitors of this. Questionnaires received back from relatives identified that they were made very welcome, and residents supported this statement. The kitchen was visited and this was found to be clean with the majority of the environmental health recommendations met. However clothes and a bicycle wheel were being stored in the dried food store and this must be addressed. Fridge, freezer and hot food temperatures were seen to have been recorded and these were within recommended parameters. Some members of the catering staff have not undertaken their food hygiene course and this must take place as soon as a space on this course becomes available. The cook states that staff visit the residents with the menu and explain the alternatives to the main menu to them and records are kept of this. A cooked breakfast is available to those who require it, although questionnaires received by the CSCI identified that this ‘ could be hotter’ when delivered to the residents. The menu is varied and there are supplies of fresh fruit and vegetables. However the supper menu is poor and on this day the supper was seen to be a cooked sausage and sandwiches and soup, followed by a cold milk pudding with orange flavouring. The quantity of the food appeared limited at this meal, residents being given one sausage, two sandwich quarters and half a cup of soup. Whilst it is appreciated that some residents will not eat a quantity of food it appeared that this was the standard and the same given to all. The home has three floors and by the time it reaches the first floor and some of the food given out, it is lukewarm. The temperature of the soup and the Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 16 plates being used for serving were not of an acceptable temperature, the sausages were almost cold. Likewise one resident, in bed, had not been positioned appropriately to eat her food and was having great difficulty in reaching the food over the bed rails. Residents identified that although the food was, in the main, good, suppers were not so good and the food needs to be hotter when delivered. It had been noted during the day that beverages were being served from ordinary metal pots without any means to conserve the heat or to ensure that the tea was not ‘stewed’ when it reaches the last resident. Older people usually treat mealtimes as a very important part of the day, and it is essential that food is well presented and of a correct temperature, therefore an immediate requirement has been made for the manager to address both this and the way trays are set up to appear attractive. The serving of food was poor, and staff assisting residents did not appear to be giving this their full attention. Further training on the importance of meals must be given. Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Complaints are dealt with in a robust and fair manner and the majority of staff have received some form of training in the protection of the vulnerable adult. Both the complaints procedure and staff training in adult protection ensure that residents can feel secure living at the home. EVIDENCE: The home has a complaints policy, which meets this standard, and this is presented both in the service users guide and in the entrance hall. One complaint was received by the CSCI and dealt with by the manager in a fair manner. This was partially substantiated. The majority of staff have undertaken some training in the protection of the vulnerable adult, this has taken place either in-house or more formally at a local centre. It is recommended that frequent updating of this take place to remind staff of their responsibilities. There is a whistle blowing policy in place and the manager must increase staff awareness of this. Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Improvements have been made in the home regarding cleanliness and tidiness and this has extended to the lounge and garden areas. This must be maintained to ensure the comfort of residents. Some maintenance matters need attending to in order to further the comfort of residents and refurbishment is needed in some areas to provide a home that residents will enjoy living in. EVIDENCE: There has been a great improvement in both the cleanliness and tidiness in the home since the last visit, when a requirement was made around this. This is expected to be enduring and will be checked on future visits. Some redecoration of rooms has taken place and there are some new carpets. The garden has now been cleared of the majority of the items that were in it and is a far more pleasant place for residents to sit in and to look upon. Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 19 However there is still a small area of items that must be discarded and a ladder stored in the garden should be made safe. Further redecoration of some rooms is required and many carpets in the home require replacing. Some paintwork throughout the home needs attention. A requirement is being made that the owner provides the CSCI with a rolling programme of this refurbishment with a reasonable, but not too distant time scale. Some rooms did not have window restrictors in place and although bars on all windows to prevent entry, these would not prevent someone climbing out. In room 20 the window is not closing properly, therefore losing heat and creating draughts and this is an immediate requirement. Rooms were seen to be homely with residents being able to bring in their own possessions, however no locks are provided to room doors. The manager must talk to residents to ascertain who wishes to have a lock to their doors and these must be fitted and keys given within the auspices of a risk assessment. This list must be ongoing and added to as new residents are admitted, records of those residents who do not wish for locks must be kept in the care plans. Some rooms had curtains coming off their hooks and the lining was torn on some curtains, the drawer front was off one of the chest of drawers and the carpet worn and torn in another room. In one room the call bell point was over the other side of the room from the resident, who was nursed in bed, and no call bell was provided. This must be addressed. Some bed linen was very thin and worn and it was noted that the home still uses paper incontinence sheets to protect the linen. This is bad practice and very uncomfortable for the residents. Bathrooms were clean and tidy and all had disposable towels and soap dispensers. The ground floor shower room requires the floor repairing and Re-grouting around the edges where the tiles meet the floor. Water temperature records for resident’s outlets were in place for the month of November 2005, but there was no evidence to show that these had been tested since 2004. - These must be undertaken on a regular basis. All temperatures were within the recommended parameters. There was no evidence in the home to show that it had been assessed by an occupational therapist, although as other homes in the group had been assessed it is likely that this has taken place. Evidence of this will be required at the next inspection or visit to the home, but no requirement has been made for this to be undertaken at present. The home was clean and tidy on this occasion and the staff were seen to be wearing aprons when entering the kitchen. Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 There are sufficient staff on duty at the present time to meet the needs of the residents. Training records are in place to identify what training the staff will need to undertake to have the knowledge to meet these needs to ensure that residents receive the best possible care. This care may be hampered by difficulties in communication between staff and residents. EVIDENCE: The duty rotas evidenced that there were sufficient staff on duty to attend to the assessed needs of the present residents in the home. However the manager must monitor this with relation to the admission of future residents and it is recommended that a balance is maintained of those residents with high nursing needs and those with low. Staff must be increased as the needs increase. The home provides two registered nurses on duty during the day and one at night with care staff to attend to the care needs of the residents. Two members of the care staff are in possession of NVQ 2 and this must be increased. Training records are in place, which identifies the courses, attended by staff. One member of staff was attending a course for updating her knowledge of syringe drivers. The manager must ensure that staff have a minimum of three training days a year, which are paid. Staff spoken with did not appear to be aware that they are entitled to this. Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 21 Work had taken place to try to ensure that personnel files contained all the documentation required by the standard, however some of this was not in place and the manager and owner must ensure that the amended requirements are met prior to employing staff. Two references and a form of identity must always be in place, as must work permits. One member of staff was working whilst waiting for her work permit and this must be in place prior to commencing work. There was no evidence in this home that GSCC booklets had been provided to staff, and this must be done. As stated previously in this report, there have been concerns raised from visitors and residents about the ability of some members of staff to communicate effectively with residents and this must be addressed by the manager, preferably at interview. Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 The standard of management within the home promotes a recognition by staff of the issues required to ensure that residents live in a home where their health, safety and comfort are paramount. Some issues around the auditing of residents money need addressing to ensure that there is evidence that residents are in receipt of interest on their savings. EVIDENCE: The relief manager, Mrs Linda Geraghty has been in post since July 2005. During her time in the home she has made an effort to address concerns raised, and to improve the general issues around the home. However at present this post is only temporary. Prior to taking up this post she was manager of an EMI home in West Sussex. Mrs Geraghty is a Registered General nurse with over 14 years experience in the care of the elderly, and is at present taking a foundation degree in health and social care which will include the Registered Managers Award. Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 23 The ethos in the home is reasonable although staff had some concerns about their role in the home and some of this related to their conditions of employment. Questionnaires received by the CSCI from relatives and residents identified that they thought that the care that they received was good and that the staff ‘ are very kind and lovely’. Residents spoken with were happy and no concerns were raised other than issues already discussed within this report. Staff felt that the relief manager was setting standards and that this was a good thing, that they were settling into this well, and achieving improvement. There is a quality assurance package in place and although much of this relates to risk assessments and quality of care within the home some efforts have been made to obtain residents views. This must be extended to other residents, visitors and stakeholders, which include other health care professionals. The owner is the appointee for some resident’s pensions. Records were kept in the home of personal allowance sent for residents from the head office, but there were no records available of how much the total amount received by the owner for each resident. It was noted that money that builds up is returned to the head office, but there were no details of which bank account this was paid into and whether residents are receiving interest on their money. There are several institutions which now set up individual accounts for residents, and the owner must now provide evidence that resident’s money is in an interest bearing account in their names, and each is receiving interest on their money. The method of keeping the money within the home needs addressing, although stored securely, a more robust method of identifying which money belongs to which resident needs to be put in place. Receipts for purchases on resident’s behalf are in place and there is a robust system of recording how money is being spent. It is recommended that the owner does not take responsibility for new residents money, that either relatives or a solicitor take this on, or that social services make the required arrangements through their money advice centre. Formal supervision of staff has not yet taken place and this must be commenced. The registered provider is making monthly visits to the home and providing reports to the CSCI and the manager. The relief manager has ensured that all records are being kept secure within the home and has commenced review of all policies and procedures. All certificates relating to utilities and services were in place and in date apart from the Landlords Gas Certificate. There was evidence that this inspection has Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 24 recently taken place although the certificate has not yet been received. However the information given at the time of the gas inspection advises that some requirements have been made and these must be addressed as an immediate requirement. There was no evidence to identify that water testing has been undertaken for Legionellas disease and it was advised that the home has static water tanks. The provider must seek advice from the environmental health agency regarding this and this has been made a requirement. COSHH data must be kept alongside the chemicals used in order to inform what immediate action must be taken in case of accident with these. The top floor boiler room must have a lock provided. Hot water notices are needed on all unregulated outlets including the hot water boiler in the kitchen and window restrictors are required on windows in some rooms. This was discussed with the manager. Staff have attended mandatory training in moving and handling, fire training and first aid. This must be continued at the appropriate intervals for all staff. Fire notices advising residents and relatives of the ‘stay put’ policy of the home must be put on residents room doors, it is recommended that this is kept short and to the point to facilitate residents memory and understanding. Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 25 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 1 1 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 2 2 3 2 2 2 3 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 2 3 3 x 2 2 3 2 Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation Reg 4(1)(2) Requirement Timescale for action 10/01/06 2 3 OP1 OP2 4 OP7 5 OP8 A Statement of Purpose which meets Schedule 1, must be available in the home. That the homes brochure contains information relevant to the home at this present time. Reg 5(2) The service users guide to be given to each service user. Reg 4 All service users to receive a (1)(b) copy of the terms and conditions, which meets the standard, on their point of moving in to the home. Evidence of this to be provided. Reg That the service users plan is 15(1)(a)(c reviewed at intervals dictated by ) the standard contains the signature of the resident or relative and consent forms for bedrails and other risks. Reg That the pressure relieving 12(1)(a) equipment is reviewed to ensure it is in line with current practice. Reg 16(m)(n) 10/12/05 10/01/06 10/01/06 02/02/06 6 OP12 That a record of resident’s social 02/02/06 interests and preferred activities is maintained within their individual plan of care. (This was a previous requirement DS0000014051.V253152.R01.S.doc Version 5.0 Page 27 Sackville Nursing Home 7 OP14 Reg 12 (2) 5. OP14 12(2), 12(3) 6. 7. OP15 OP15 Reg 16(2)(i) Reg 16(2)(i) Reg 16 (2)(i) Reg 12 (2) Reg 23 (2)(b) 8. 9 10 OP15 OP15 OP19 11 OP22 13 (4) 12 OP24 Reg 23(2)(b) 13. OP24 Reg 23(2)(b) June 2006) that a programme of activities is displayed and records kept of those taking part. That staff are aware of the choices of service users regarding controlling their environment such as televisions being left on in room. That staff are aware of the restriction that can be imposed by over bed tables on residents movement and aim to reduce this That the supper menu is reviewed That a method of ensuring that food and beverages provided to service users are served at an optimum temperature That the staff are aware of the importance of presentation of meals. That staff are aware of the need to ensure service users can reach their meals. 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, this is supplied to the CSCI for discussion. That call bell provided in the room identified to the manager is made suitable to the needs of the service user. That curtains are kept on their hooks and in a good state of repair. That the window in the room identified is repaired to enable it to be closed. The ground floor shower room floor is repaired and resealed. That linen is replaced as required. DS0000014051.V253152.R01.S.doc 20/12/05 20/12/05 20/12/05 28/11/05 28/11/05 28/11/05 20/01/06 28/11/05 10/12/05 10/01/05 Page 28 Sackville Nursing Home Version 5.0 14. OP24 Reg23(2)( b) Reg 12 (4) Reg 13(3) Reg 18 (1)©(i) Reg 19 Sched 2 15 OP24 16 17 18 OP26 OP28 OP29 19 OP30 Reg 18 (1) Reg 20(1)(a) 20 OP34 21 OP34 Reg 20 (3) 22 23 24 OP36 OP38 OP38 Reg 18(2) Reg 13(4) Reg 13(4) 25 26 OP38 OP38 Reg 13(4) Reg 13(4) . That the window in the room identified is repaired to enable it to be closed. The drawer on the furniture identified is repaired That service users are given the choice of having lockable doors to rooms and their wishes recorded. That all catering staff undertake the food hygiene course. That staff continue to be encouraged to study for NVQ2 That staff do not commence work until all documentation as required by the regulations including work permits are in place. That the staff are in possession of sufficient fluency of language to enable them communicate well with residents. That service users monies are paid into an account which is in the name of the service user or service users and interest allocated to them. That the registered person ensures that no person acts an agent for the service user (as far as is practicable) and that full documentation is available at inspection relating to service users monies. That staff receive supervision in compliance with the standard. That all COSHH data is kept with the substances to which it relates That clothing and the bicycle tyre are removed from the food storage area and the ladder from the garden That the lock is put on the top floor boiler room. That advice is sought regarding protection from Legionellas disease. That the water DS0000014051.V253152.R01.S.doc 28/11/05 10/01/06 10/01/06 10/01/05 28/11/05 28/11/05 01/01/06 01/01/06 01/01/06 28/11/05 28/11/05 28/11/05 20/12/05 Sackville Nursing Home Version 5.0 Page 29 27 OP38 Reg 13(4) temperatures are recorded regularly and that hot water notices are put on unregulated outlets That all windows have window restrictors in place. 28/11/05 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 2 3 4 5 Refer to Standard OP1 OP7 OP8 OP9 OP10 Good Practice Recommendations That the manager has a copy of the statement of purpose and service users guide when assessing residents to enable them to make an informed choice on the home. That the label identifying the catheter batch number is kept in the care plan on change of catheter.. That the use of paper incontinence sheet protectors is discontinued. That eye drops have their date of opening recorded. That a telephone is provided that those in their rooms can access. Sackville Nursing Home DS0000014051.V253152.R01.S.doc Version 5.0 Page 30 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 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.V253152.R01.S.doc Version 5.0 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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