Inspection on 11/11/05 for Seven Hills Nursing Home

This inspection was carried out on 11th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Seven Hills Nursing Home 19/07/06

Seven Hills Nursing Home 21/06/05

Seven Hills Nursing Home 23/02/05

Seven Hills Nursing Home 27/07/04

Seven Hills Nursing Home 10/02/04

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

CARE HOMES FOR OLDER PEOPLE Seven Hills Nursing Home 17 Cherry Tree Road Nether Edge Sheffield South Yorkshire S11 9AA Lead Inspector Marina Warwicker Unannounced Inspection 11th November 2005 09:45 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 Seven Hills Nursing Home DS0000021811.V263596.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. Seven Hills Nursing Home DS0000021811.V263596.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Seven Hills Nursing Home Address 17 Cherry Tree Road Nether Edge Sheffield South Yorkshire S11 9AA 0114 255 3023 0114 255 3023 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) Beech Lodge Ltd Anna Frans Melisse Care Home 24 Category(ies) of Dementia - over 65 years of age (24) registration, with number of places Seven Hills Nursing Home DS0000021811.V263596.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 2005 Brief Description of the Service: Seven Hills nursing home consists of a converted villa with a purpose built extension. It is a small privately owned care home. It provides nursing care for elderly mentally infirm people. The home is situated in the residential area of Nether Edge. It lies within easy access of a regular bus service and Sheffield City Centre. Seven Hills Nursing Home DS0000021811.V263596.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was carried out on 11th November 2005. The inspector spent time observing care delivery, speaking to the service users and staff. A selection of staff files and residents’ care plans were checked and feed back on the findings was given to the manager. During the inspection the inspector did not come into contact with relatives of the service users. Therefore details of seven relatives were randomly selected and questionnaires have been sent off to find out about their views of the home. Eleven staff have also been contacted to gain their perception of the home. The outcome of the questionnaires will be discussed with the manager. What the service does well: What has improved since the last inspection? The care plan documentation and the care staff involvement in the reviews of care plans have improved. The staff morale was positive during this inspection. The home was clean, tidy and did not emit any unpleasant odour. Wheelchairs were available for the residents. Seven Hills Nursing Home DS0000021811.V263596.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Seven Hills Nursing Home DS0000021811.V263596.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Seven Hills Nursing Home DS0000021811.V263596.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3&5 Trial visits are encouraged by the home. Prior to moving into the home all residents have their needs assessed to ensure that the home is able to cater for them. The residents or their next of kin are provided with a statement of terms and conditions following admission to the home. EVIDENCE: Three service user plans were checked, staff on duty were interviewed and the admission process was discussed with the manager. All three service users had contracts. The placing authorities had signed two contracts and the next of kin of the third service user had signed the statement of terms and conditions. This is due to the residents not having the capacity and therefore unable to understand and sign the documents. As explained in the previous inspection report the care staff said that the service users benefited by moving into the home on a trial basis rather than having day visits. Seven Hills Nursing Home DS0000021811.V263596.R01.S.doc Version 5.0 Page 9 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&11 The residents’ health, social and personal care needs are well documented in the care plans. A range of health care professionals visit the home to assist in maintaining the care needs of residents. Medication procedures provided protection to residents. Residents’ privacy and dignity is maintained. EVIDENCE: The three service user plans checked had been revised on the basis of the needs assessments and the outcomes of the monthly reviews. The documentation has improved and the care plans accurately reflect the residents’ needs. The supplying pharmacist has carried out an audit on 29th September 2005 and made the following recommendations. They are: 1. The home requires a new trolley to cope with the amount of medication. 2. An up to date British National Formulary (BNF) should be obtained for the staff to use. 3. The stock levels of medication should be reduced. 4. There needs to be regular checks and disposal of unwanted and expired medication. Seven Hills Nursing Home DS0000021811.V263596.R01.S.doc Version 5.0 Page 10 The care staff said that they were encouraged to read the care plans by the manager. They said that by having access to the care plan they are able to find out how the residents had been during their days off. The care staff said that the nurses were involving them in the planning and reviewing of care plans. Out of the three care plans checked one had documentation relating to residents’ last wishes. The staff said that the relatives did not want to discuss the subject of death, therefore they had not filled in this section. The manager said that arrangements were being made for staff training on palliative care, pain management and bereavement counselling. The staff confirmed this during interviews. Seven Hills Nursing Home DS0000021811.V263596.R01.S.doc Version 5.0 Page 11 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): 12,14,&15 The residents have a choice of lifestyle within the home and they are able to maintain contact with family and friends. Meals served at the home are of a good quality and choices of meals are on offer at meal times. EVIDENCE: The inspector observed the home’s routine between mid morning and late afternoon. The residents were able to get up when they wanted and have breakfast at their leisure. Lunch was served and residents were given time to eat. Food served was appealing and the staff knew the residents’ likes and dislikes. The cook had good knowledge of the residents’ eating habits and prepared meals to tempt the individuals. Residents were given snacks and drinks throughout the day at their request. The majority of residents needed prompting or helping at mealtime. The staff were available and helped those who needed help. The activities co-ordinator was interviewed about her contribution to the residents and the home. She was innovative and enthusiastic about her role within Seven Hills. She also had a good understanding of the recreational needs of each resident. The Inspector encouraged the activities co-ordinator to share her findings with the care staff to promote a better understanding of the recreational needs of the residents. Discussions took place between the Seven Hills Nursing Home DS0000021811.V263596.R01.S.doc Version 5.0 Page 12 manager and the Inspector as to how this information should be shared and put to good use among other staff. Seven Hills Nursing Home DS0000021811.V263596.R01.S.doc Version 5.0 Page 13 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 Although the home has a complaints policy which, is compliant to the CSCI requirements the staff are not in the habit of recording concerns / complaints made by residents, relatives or any others. The staff are aware of the residents’ rights and the residents are protected from abuse. EVIDENCE: The manager said that there were no complaints recorded in the complaints book. However, during conversation with the manager and the staff there was evidence that concerns/complaints had been made and the home had dealt with them effectively. The manager was informed that if recording of complaints was seen as a negative act by the staff, it was acceptable to record compliments and complaints. The information could be used as part of the quality audit for the home. Not all staff had attended training on Adult protection and recognition and dealing with abuse. Out of four staff files checked one had attended the training. Seven Hills Nursing Home DS0000021811.V263596.R01.S.doc Version 5.0 Page 14 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): 19,22,25&26 The environment and cleanliness of Seven Hills has continued to improve. The residents have access to safe and comfortable indoor communal areas. The outdoor facilities for the residents need to be improved by springtime in order for the residents to enjoy the garden and be in the fresh air. EVIDENCE: The indoor communal areas were comfortable and clean. The residents were able to walk around these areas without any restrictions. The staff interacted with the residents and offered help and companionship. The outdoor communal area was an enclosed area where residents will be able to spend time with the staff or relatives during good weather. The manager explained that there are plans to make this area safe, welcoming and acceptable for the use of residents for the Spring/ Summer time next year 2006. There were sufficient toilets near the communal areas and the residents used these. Seven Hills Nursing Home DS0000021811.V263596.R01.S.doc Version 5.0 Page 15 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 Staff were employed in sufficient numbers to meet the needs of residents. The recruitment procedure of staff is not robust. The staff have training and development programmes to help them achieve competency. The content and the length of the service needs to be amended to reflect the staff needs. EVIDENCE: On the day of inspection the manager was working as the nurse and was counted in the staff numbers. However, she explained that she had recruited nurses to the vacancies and that from week beginning 21/11/05 she would be nominating a nurse on each shift; thereby giving her a supernumerary status to focus on the management aspects of her job and the day to day running of the home Four staff files were checked and the following points were identified. The manager was made aware of these: • One file did not have the date the staff commenced employment at Seven Hills. • Two staff files did not have any evidence of Induction training. But the manager said that they had received training. One staff who was on duty had not had any induction training. The manager told the Inspector that the particular staff was to receive induction on the afternoon of the inspection. • No evidence of face to face interview (the questions asked and the scoring given at the interview). Seven Hills Nursing Home DS0000021811.V263596.R01.S.doc Version 5.0 Page 16 • • • • • No letters of job offer were found in the files. The manager said that the job offer was made by a telephone call. Out of four staff one did not have any written references on the file, another staff’s previous employer had given two unsatisfactory references. A further two references had been sought and they were satisfactory. There was no risk assessment based on the information from the previous employer and there was no documentation of the decision by the manger to obtain further references. All four staff files had gaps and a lack of information on the individuals’ employment histories. Two staff had not received CRB clearance. One staff had used a previous employment CRB clearance documents. Out of four staff three did not have photo identification. The training files of the same four staff were checked. The manager said that three staff had received induction training and one of the new staff was to receive induction training on the day of the inspection. The training referred to here is the mandatory training i.e. fire safety, moving &handling, health &safety, COSHH, infection control and any specific training relating to the home. So, that the members of staff will be aware of the safe working practices at the home. Staff said that they were encouraged by the manager to work towards the NVQ level 2 in care. Seven Hills Nursing Home DS0000021811.V263596.R01.S.doc Version 5.0 Page 17 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): 31,32,33,34,35,36,37&38 Residents and staff benefited from the ethos, leadership and management approach. There was a positive style of management in the home and staff morale has improved. Staff were supervised. The home’s policies and procedures promote the health, safety and welfare of residents and staff. EVIDENCE: The registered manager is in the process of completing the manager’s award. Staff said that their morale was improving and that they enjoyed working at the home. They said that the owner often visited the home and listened to them. The manager said that the majority of the residents’ finances were taken care of by their relatives and that the owner of the home was appointee for two Seven Hills Nursing Home DS0000021811.V263596.R01.S.doc Version 5.0 Page 18 residents. She also assured the Inspector that there was adequate insurance cover and that to the best of her knowledge the company remains viable. Staff said they were receiving supervision and management support on a regular basis. However the manager is exploring a better tool to use for supervision. Records were securely stored around the home, which protected the residents’ best interests and confidentiality. At the time of inspection fire exits were clear and window restraints were in place to prevent falls. Hazardous products were safely stored in the home. During care plan and other document checks it was evident that the staff were not recording and reporting all accidents, injuries and incidents. The staff were not familiar with the type of incidents and accidents they needed to report. The length and the content of the staff induction training are not in line with the National Training Organisation and Work Force Training programmes. The manager had carried out risk assessments on safe working practice topics for staff i.e. manual handling, COSHH. Seven Hills Nursing Home DS0000021811.V263596.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X 3 X X 3 3 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 2 2 Seven Hills Nursing Home DS0000021811.V263596.R01.S.doc Version 5.0 Page 20 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 OP9 Regulation 13 Requirement Timescale for action 30/12/05 2 OP30OP18 OP11 18 3 OP16 22 The management must make arrangements to comply with the pharmacist’s requirements. a) Purchase a medicine trolley to securely store the medication of the residents. b) Obtain an up to date BNF c) Nursing staff monitor the levels of the stock drugs held at the home. Dispose of unwanted and expired drugs according to the medicines act and the pharmacy guidance. 09/08/05 The staff must receive training on topics including palliative care, pain control, bereavement councilling, Adult protection, dealing with allegation of abuse and subjects covering mandatory training such as Moving and handling, COSHH, Health and Safety, first aid, food hygiene, infection control and continents management. Previous requirement Mandatory training 09/08/05 Other training arrangements by 27/09/05 The manager must provide the 21/06/05 CSCI at its request a summary DS0000021811.V263596.R01.S.doc Version 5.0 Seven Hills Nursing Home Page 21 4 OP19 23 5 OP27 18 6 OP37OP29 19, schedule2 7 OP38 17,37 8 OP30OP38 18 of the complaints made during the preceeding twelve months and action that was taken in response. Previous requirement The outdoor communal area must be made suitable for the use of service users. Previous requirement 27/09/05 and work has begun. There must be sufficient staff deployed in appropriate numbers and skill mix to reflect the assessed needs of the service users. Previous requirement The registered manager must operate a thorough staff recruitment procedure complying with the Care Homes Regulations and associated schedule. Immediate requirement. The staff must notify the CSCI of any event in the care home which adversely affects the wellbeing or the safety of any resident. This includes accidents and incidents. All new staff must receive appropriate induction prior to commencing work at the home. Immediate requirement. 17/03/06 30/08/05 11/11/05 11/11/05 11/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Seven Hills Nursing Home DS0000021811.V263596.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Seven Hills Nursing Home DS0000021811.V263596.R01.S.doc Version 5.0 Page 23 - 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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