Inspection on 21/06/05 for Seven Hills Nursing Home

This inspection was carried out on 21st June 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 11/11/05

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 S11 9AA Lead Inspector Marina Warwicker Unannounced 21 June 2005 07:00. 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 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 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 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 Not available Beech Lodge Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Anna Melisse,acting manager Care Home with Nursing 24 Category(ies) of DE Dementia over 65: 24 registration, with number of places SEVEN HILLS NURSING HOME 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 23 February 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 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted between 7am and 3pm on Tuesday 21st June 2005. The inspector took the opportunity to speak to the night staff and observe the residents during the early hours. The hand over report was observed and time spent speaking to residents and relatives who visited during the day. Five staff were interviewed and the inspector introduced herself to all staff on duty and invited their comments about the service. The manager and the staff seemed open, honest and helpful with the inspection process. What the service does well: What has improved since the last inspection? What they could do better: All levels of care staff should be involved in the planning and delivery of care. SEVEN HILLS NURSING HOME 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 Page 6 Care staff need to be given the opportunity to read the care plans and understand the treatment the residents receive. The staff need to be supervised and supported by experienced staff/nurses. There needs to be a planned programme of training and development for all staff so that they feel valued and continue to develop and give their full commitment. All mandatory training must be brought up to date without delay. There needs to be systems in place to enable staff to become familiar with the home’s policies and procedures. The staffing levels must reflect the present dependency levels of the residents. Every effort must be made to stimulate residents through and recreational activities in and outside the home. When arranging activities each resident’s preference, need and capacity should be taken into account. 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 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection SEVEN HILLS NURSING HOME 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 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 standard(s) 1,3,4 and 5. However standard 6 is not applicable. The home provides the prospective residents and their families with sufficient information to make an informed choice. Service users, before moving into the home, take part in a professional needs assessment by the placing authorities and are assured by the home that the identified needs will be met. The home encourages trial visits by prospective service users, their families and friends to help them decide on the suitability of the service. EVIDENCE: The relatives and staff said that there was information available to check what type of care was offered at the home. Three care plans were checked. On the files there were needs assessments carried out by the placing authorities for the respective residents. There were also copies of the home’s individual assessments of the residents indicating how the identified needs were to be SEVEN HILLS NURSING HOME 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 Page 9 met. One service user and a relative said that they were confident that the home was suitable when they made trial visits and met the staff and the other residents. SEVEN HILLS NURSING HOME 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 and 11 The service user plans generated from the needs assessments are fragmented and require reconsideration. The care plans do not reflect changing needs and the current objectives based on the risk assessments carried out by the staff at the home. In re-evaluating the care plans the home will be able to set out in detail the action to be taken by staff to ensure all aspects of care needs are addressed and outcomes of the risk assessments are used in the daily delivery of care. This will enable residents to receive appropriate individual care. The residents are treated with respect and their right to privacy is valued by the staff. However, incontinence pads are kept on view in the communal toilets compromising the dignity of the residents. The relatives are consulted about funeral arrangements when the staff feel it’s appropriate. So that the residents’ last wishes are respected. EVIDENCE: Although several care plans were seen; three were checked in detail. There were risk assessments on falls, movement and handling and tissue viability but there were no action plans based on the outcome of the assessments. There was evidence of the present manager reviewing the care plans. SEVEN HILLS NURSING HOME 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 Page 11 The staff follow the medication administration guidelines set out by the NMC – Nursing And Midwifery Council- when administering medication to residents. Failure to adhere to the guidelines will result in disciplinary action towards the nurse. None of the residents in the home have the capacity to self-medicate; therefore the nurses administer the medication. There is a lack of input from the supplying pharmacy, which is causing gaps in the management of medication by the home. Inadequate support and audit can result in mismanagement of medication at the home. The pads must be stored where residents are able to access but not on full view of the visitors and any others. The care staff were not encouraged to read the care plans and they relied on the brief handover sessions to obtain information. The staff said that this was not satisfactory and that they would like to be more involved in the planning of care and know more about the treatment the residents receive. The supplying pharmacist had not visited the home for over a year and therefore pharmacy audit had not been carried out. The areas highlighted by the last pharmacy audit had not been checked. The three care plans checked had documentation relating to residents’ last wishes. There had not been any formal training on palliative care, pain management or bereavement counselling; this was confirmed by the manager and the staff during interviews. SEVEN HILLS NURSING HOME 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 Page 12 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 standard(s) 12,13,14 and 15. The residents are given choices in relation to daily routines, meals and mealtimes. There is a lack of leisure and social activities at the home, which contributes to the residents becoming restless and bored. There is no restriction on visiting and the staff survey the visitors when they enter the home and are able to protect residents from unwelcome visitors. Those who need help with feeding receive this in a discrete manner by the staff, thereby preserving their dignity, however staffing levels were not sufficient to deal with this demand. EVIDENCE: The inspector observed the home’s routine from 7am until 3pm. The residents were able to get up when they wanted and have breakfast at their leisure. All of the residents needed varying degrees of help with eating which made extra demands on care staff time. On the day of inspection one care staff was missing and this may have contributed to the busyness of staff. Food served is appealing and the staff know the residents’ likes and dislikes. Residents are given snacks and drinks throughout the day at their request. The majority of residents need prompting or helping at mealtime. SEVEN HILLS NURSING HOME 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 Page 13 A new activities co-ordinator commenced work on the day of inspection. The relatives said that they were disappointed at the lack of activities at the home for the residents. The manager recognised this and was taking action by employing a co-ordinator. One of the residents said that he/she was looking forward to trips out. The manager informed the inspector that the handyman had been trained to drive a mini-bus and the trips would recommence. The residents, relatives and the staff said that the food was varied and was plentiful. The relatives said that the residents could have snacks and drinks when they wanted. During staff interview it was ascertained that the staff had a good understanding of the resident group and the need to offer the residents frequent snacks and drinks. SEVEN HILLS NURSING HOME 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 Page 14 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 standard(s) 16,17 and 18 The relatives and residents are given the opportunity to raise their concerns and complaints to staff and the manager. The complainants are not penalised and corrective action is taken without delay. The staff are not in the habit of recording concerns and complaints, therefore there were no records of any recent complaints. The staff are aware of the residents’ rights and the residents are protected from abuse by the other residents, relatives or staff. Foe those residents who lack in capacity, an advocacy service is offered. EVIDENCE: The complaints procedure was displayed in the reception area. The staff and the relatives said that they had read the procedure. The manager said that there were no complaints recorded in the complaints book. However, during conversation with relatives and staff there was evidence that concerns/complaints had been made and the home had dealt with them effectively. Not all staff had attended training on Adult protection and recognition and dealing with abuse. Staff interviewed were able to verbalise who to report to and what to do if they suspected abuse taking place at the home. SEVEN HILLS NURSING HOME 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 Page 15 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 standard(s) 19,20,21,22,23,24,25 and 26 The layout and the location of the home are suitable for its stated purpose. The home is accessible, safe and on the whole meets the needs of the residents who live at Seven Hills. The environment generally is clean and safe for the residents. The grounds are kept tidy and there is an outdoor communal area, which is for the residents to utilise. However, this is not an area which is pleasant, inviting or safe for the specific resident-group. Therefore the residents and their relatives do not use it. The laundry facilities are on site and away from the cooking area so that soiled and infected clothing are washed in the premise preventing unnecessary spread of infection. SEVEN HILLS NURSING HOME 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 Page 16 EVIDENCE: The manager witnessed the findings regarding the general cleanliness of the environment including the dining room. The dining room emitted unpleasant odour and had not been cleaned from the previous day. There is a lack of wheel chairs for the residents’ use. The residents are having to share the use of wheel chairs when transported from their bedroom to the communal areas. Most rooms are clean and equipped to suit the needs of the occupants. Some rooms are personalised with the residents’ own possessions. The outdoor communal area was an enclosed area where residents will be able to spend time with the staff or relatives. But the ground of this area was uneven, rough and not safe for the client group. The laundry included hand-washing facility for staff when they needed to handle soiled and infected material. The washing machine programme met the disinfection standards (i.e. minimum 65 degrees centigrade for not less than 10 minutes wash). The relatives made positive comments about the cleanliness of linen and personal clothing received back from the laundry. There were sufficient toilets near the communal areas and the residents used these. SEVEN HILLS NURSING HOME 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27. The dependency levels of the residents are high and this was not reflected in the number of staff on duty. On night duty the high dependency levels made it difficult for staff to manage the workload. Therefore in general the staff are focused on completing the essential care tasks and not spending time chatting and/or involving themselves in activities with the residents. EVIDENCE: During the inspection there were 3 night staff on duty, followed by five day staff which included the manager. The inspector was informed that a carer had rung in sick for the day shift and that they were unable to get a substitute. Out of 23 residents, one was in hospital, 13 needed two staff to care for their needs and 9 needed at least one carer. Staff were observed to carry out duties without supervision. They were unable to sit and chat or take service users outside for a short time. SEVEN HILLS NURSING HOME 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,35,36 and 38. The manager is new in post and she is getting to know the staff and residents. The residents’ pocket monies are safely handled by the home therefore giving the relatives confidence in the service. The staff are not regularly supervised. This is resulting in some complacency among staff and in some irregularities in care practices. Staff are not familiar with the frequently used policies and procedures of the home. This lack of knowledge can result in inconsistency and incorrect handling of issues. Not all staff are trained in health & safety, COSHH, moving and handling and food hygiene. There are gaps in the training and updates of night staff. Such gaps in training can put residents and staff at risk. SEVEN HILLS NURSING HOME 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 Page 19 EVIDENCE: The manager is going through the process of registering with the CSCI. The inspector checked the staff training records and found several gaps. The staff had not received regular supervision. Written records of all transactions are maintained. Records and receipts are kept of possessions handed for safekeeping by the residents and/or their relatives. Staff were not familiar with the home’s policies on health and safety, COSHH, food hygiene, infection control and risk assessment of the environment. Three residents pocket money records were checked and they were maintained satisfactorily. SEVEN HILLS NURSING HOME 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 2 3 2 3 3 3 2 STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 2 3 x x x 3 2 x 2 SEVEN HILLS NURSING HOME 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 Page 21 YES 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 7&8 Regulation 15 Requirement The service user plan must be formulated based on the assessment drawn up by the professionals and the outcome of the homes risk assesments. Previous timescale 31/05/05 Timescale for action 30/08/05 2. 12 16 The home must provide activities 30/08/05 that reflect the recrerational needs of the residents. Previous timescale of 30/04/05. The manager must provide the CSCI at its request a summary of the complaints made during the preceeding twelve months and action that was taken in response. The outdoor communal area provided for service users must be suitable for activities appropriate to the circumstances of the service users. The service users must have access to wheelchairs to help with their independence and mobility. To commence from 21/06/05 3. 16 22 4. 20 23 27/09/05 5. 22 16 30/08/05 SEVEN HILLS NURSING HOME 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 Page 22 6. 27 18 There must be sufficient staff deployed in appropriate numbers and skill mix to reflect the assessed needs of the service users. 30/08/05 7. 36 18 All staff must receive formal 30/08/05 supervision at least six times a year. The supervision must cover all aspects of practice, philosophy of care and career development. There must be documentation in each staff file to support this. Previous timescale 30/04/05 8. 38 12 To promote the health and 30/08/05 welfare of the service users the manager must make proper provision for the care, treatment, education and supervision of service users. The manager must provide appropriate training to all care staff on topics including palliative care, pain control, bereavement councilling, Adult protection, dealing with allegation of abuse and subjects covering mandatory training such as fire safety, Moving and handling, COSHH, Health and Safety, first aid, food hygiene. The dining room must be cleaned after use. Mandatory training to be updated by 09/08/05 other training must be available by 27/09/05 Immediate. 21/06/05 9. 11,18,38 18 10. 11. 26 10 16,23 23 To maintain the privacy and 30/08/05 dignity of the residents the home must provide suitable storage space for the packs of continence pads. SEVEN HILLS NURSING HOME 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 Page 23 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 9 Good Practice Recommendations The manager should seek information and advice from the supplying pharmacist regarding medicine policies within the home. The pharmacists audit should be used when monitoring medicine management at the home. SEVEN HILLS NURSING HOME 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Sheffield South Yorkshire S9 2LR 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 20050825 Seven Hills SUI X00015 J55 V219905 S21811 Stage 4.doc Version 1.30 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!