Inspection on 10/02/06 for Shottendane Nursing Home

This inspection was carried out on 10th February 2006.

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

Shottendane Nursing Home 16/07/08

Shottendane Nursing Home 15/08/06

Shottendane Nursing Home 01/07/05

Shottendane Nursing Home 30/11/04

Shottendane Nursing Home 26/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

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 Shottendane Nursing Home Shottendane Road Margate Kent CT9 4BS Lead Inspector Sandra Crosby Unannounced Inspection 10th February 2006 12:00 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 Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 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. Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Shottendane Nursing Home Address Shottendane Road Margate Kent CT9 4BS 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) 01843 291888 01843 292140 Mr Norman Edward Temple Mr Keith James Breading, Mr Leslie Roy Gibbs, Mr Laurence John Waitt Vacant Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38), Terminally ill (5) of places Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 24 of the beds are registered for nursing patients and 14 for residential clients To admit one (1) Service User, whose date of birth is 13.12.1944. To admit one (1) Service User, whose date of birth is 06.09.1946. To allow Room 23 to be used as a nursing bed on a temporary basis, until a registered nursing bed becomes available for a Service User whose date of birth is 10/03/1926. To admit one (1) Service User, whose date of birth is 15/01/1942 for resipte care up until 31 January 2006. 1st July 2005 5. Date of last inspection Brief Description of the Service: Shottendane Nursing/Residential Home is a large detached property, which was constructed in 1910 in the country manor style. Following a major conversion programme, it was registered as a nursing/residential home in 1989.Service User accommodation is on three floors, comprising of single and double bedrooms 20 of which have en suite WC and washbasin facilities. Nursing bedroom accommodation is situated on the ground and first floors and residential accommodation is situated on the second floor. The day space consists of two lounges and a dining room on the ground floor and a lounge/dining room on the first floor. There is a small room on the first floor, which can be used either as a quiet room or overnight accommodation for relatives. A passenger lift provides access to all levels. Each bedroom has a TV point and a call alarm and some bedrooms have telephone line points. The home is situated in extensive well-maintained secluded grounds and backs onto farmland. There are ample car parking facilities. The home is situated in a residential area and is approximately two miles from the centre of Margate. Public transport to and from Margate is available a short distance from the home. Margate town has many facilities expected of a seaside town, including beach and promenade as well as banks, library, cinema, railway station, places of worship and shops. Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspector visited the home on Tuesday 07 February 2006 to carry out the unannounced inspection. Unfortunately at that time the Manager was undertaking a training day and as the focus of the unannounced visit was to check on compliance with the requirements and recommendation made in the announced inspection report dated 01 July 2005, together with discussing two issues of concern that had been raised with the Commission. For this reason the Inspector decided to visit again. The inspection visit was unannounced and carried out over two days on Friday 10 February 2006 between 12.00 and 15.00 and on Monday 13 February 2006 between 11.15 and 13.15. The majority of the key standards were inspected at the announced inspection visit dated 01 July 2005. The atmosphere of the home was welcoming, calm and relaxed, and the home was clean and orderly at the time of the inspection visit. What the service does well: What has improved since the last inspection? The home continues to maintain and provide a good standard of service. Staff training is ongoing at the home. Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 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. Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 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 Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 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): 1,3,6 The homes Statement of Purpose and Service User Guide provide Service Users and prospective Service Users with the information they need to make a decision about moving into the home. Service Users move into the home knowing that their needs can be met and that their independence will be maximised and promoted. It is not the general policy of the home to admit Service Users on a short-term basis, and this standard was judged as not applicable at this inspection visit. EVIDENCE: Standards 1 and 3 were judged as standard met, Standard 6 was judged as not applicable at the announced inspection visit dated 01 July 2005. These standards were not inspected at this inspection visit, and the information below refers to the judgement made at the announced inspection visit. Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 Page 9 The Statement of Purpose and Service User Guide were seen, and the nurse in charge agreed for a small amendment to be made. Both documents are well presented and suitable for purpose. It was seen that a completed Enquiry Form, together with pre-assessment information completed on admission and a hospital assessment information were available for a recently admitted Service User. Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 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 the following standard(s): 7,8,9,10 The care planning system meets the requirements of the national minimum standards and regulations, however it was found that some information in relation to health matters was not recorded, and that this could be detrimental to the well being of Service Users. The health needs of Service Users in the main are well met, but again not always appropriately recorded. The systems for medication administration are good with clear and comprehensive arrangements being in place to ensure Service Users medication needs are met, however recording issues were discussed. Personal care is offered in a way to protect Service Users privacy and dignity. Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 Page 11 EVIDENCE: Standard 10 was judged as standard met, and Standards 7,8 and 9 were judged as nearly met, at the announced inspection visit dated 01 July 2005. The judgement for these standards remains the same at this inspection visit. The Service User Plan system was audited in December 2005 by a Specialist Support Nurse for Care Homes (Nursing) the Manager reported, and stated that recommendations made were to be implemented. Two Service User Plans were seen, and overall the system in use includes all components as required by regulation. Discussion took place in relation to the reviewing of the documentation, as this appeared muddled, and the Manager agreed to address this issue. The tissue viability/wound records showed improvement, however there was discussion about the review date, and it was seen that this was not always adhered to. There was also a written reference to the need for a swab to be taken, and no further evidence to show that this had been carried out. The Manager agreed to take action in relation to this issue. Medication records were seen and indicated that overall they were appropriately signed and up to date, however the number of gaps seen was discussed with the Manager. The storage of medication was not seen at this inspection visit. Observation and discussion with Service Users at the announced inspection visit confirmed that the standard of personal care provided was delivered to a high standard. Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 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 the following standard(s): 12,13,14,15 Service Users indicated that the lifestyle they experience in the home met their expectations. Service Users are able to maintain contact with family and friends together with access to the local community as they wish. Service Users are enabled to exercise choice and control over their lives. The meals in the home are good offering both choice and variety, and catering for special diets. EVIDENCE: Standards 12,13 and 14 were judged as standard met, Standard 15 was judged as standard exceeded at the announced inspection visit dated 01 July 2005. These standards were not inspected at this inspection visit, and the information below refers to the judgement made at the announced inspection visit. Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 Page 13 It was seen that lifestyle at the home was relaxed and that Service Users were able so far as is possible to carry on their lifestyle expectations. Visitors were seen around the home during the time of the inspection visit, and Service Users talked about family and friends that visited them at the home. It was seen from the accompanied tour of the home and talking to Service Users that choices in relation to for example whether they spend their time in their bedroom or in the communal areas, whether they join in activities, whether they spend time in the lovely garden areas. The food menus were seen, together with observation of the meals provided on both days of the inspection. Service Users gave positive comments about the food provided and were aware that alternatives were available. It is indicated that the home maintains a high standard in relation to variety and presentation of food. Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 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 the following standard(s): 16,18 The home has a satisfactory complaints system with evidence that Service Users feel that their views are listened to and acted upon. Management confirmed knowledge and understanding of Adult Protection issues that protects Service Users from abuse. EVIDENCE: Standard 16 was judged as standard met, at the announced inspection visit dated 01 July 2005. The home has a complaints procedure, and the two issues of concern that the Commission had been informed about were discussed. In relation to one of the issues appropriate action had been taken, and in relation to the second issue the Manager agreed to take further action in order to hopefully resolve any problem. The training matrix indicates that several staff at the home have undertaken training in relation to the Protection of Vulnerable Adults. Following discussion it is recommended that all staff undertake training in relation to the Protection of Vulnerable Adults. Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 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 the following standard(s): 19,26 The standard of the environment within the home is good providing Service Users with an attractive and homely place to live. The large garden areas are attractive and well maintained. The home was clean and pleasant at the time of the inspection visit. EVIDENCE: Standard 19 was judged as standard met, and Standard 26 was judged as nearly met at the announced inspection visit dated 01 July 2005. These standards were not inspected at this inspection visit; however from discussion Standard 26 was judged as standard met at this inspection visit. The information below mainly refers to the judgement made at the announced inspection visit. Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 Page 16 An accompanied tour of the premises was made with the Manager and Nurse in Charge. Bedrooms were well appointed and all contained personal possessions of the Service Users. Service Users spoken to confirmed that they liked their bedroom and that the furniture was arranged to suit their needs. The laundry assistant provided information about the laundry system in use, and it was seen that all laundry was dealt with appropriately. It was discussed with the Manager that the laundry area needed to be re-painted and re-tiled as appropriate in order to maintain infection control standards. The Inspector was told at this visit that the work to the laundry area was in the process of being completed. Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 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 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 are multi-skilled ensuring good quality care and support, and staff morale is good resulting in a workforce that works positively with Service Users. Staffing numbers are sufficient for most of the time to meet the needs of the current group of Service Users. The home uses a thorough recruitment system that ensures that Service Users are supported and protected. Staff training is ongoing at the home. EVIDENCE: Standard 27 was judged as standard nearly met at the announced inspection visit dated 01 July 2005. The staff rota was seen, and it was indicated on the days of the unannounced inspection visit that there were sufficient staff on duty at that time to meet the needs of the current group of Service Users. No judgement was made in relation to this standard at this visit, and the staffing levels at the home will be further assessed at the next inspection visit. Four staff files were viewed at the announced inspection visit and showed that the home carries out a thorough recruitment procedure. Discussion took place in relation to the receiving a POVA First check prior to the commencement of any new member of staff. Management agreed that following recent changes that this would now be done. Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 Page 18 The training matrix was seen for the home, and indicates that staff training is ongoing at the home. Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 Page 19 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): 31,33,35,36,38 Service Users benefit from a well run home, and on the whole the health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: Standard 38 was judged as standard nearly met at the announced inspection visit dated 01 July 2005. The judgement remains the same at this inspection visit. The Fire Log Book was again seen and on the whole the regular monitoring checks has been recorded. It was discussed that Fire training has been undertaken by staff, however practice fire drills have not been undertaken and a requirement is again given for this issue to be addressed as soon as possible. The personal allowance monies records were seen and indicated that a sound accounting system was in place. Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 Page 20 When examining the staff files, it was seen that written supervision records are kept. The Manager said that there has been quality assurance questionnaires sent before her appointment at the home, and will be continuing this system in due course. Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 Page 22 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. 2. Standard OP7 OP8 Regulation 15(1)(b) 13(1)(b) Timescale for action Keep the service users plan 13/02/06 appropriately under review – Previous timescale 04/07/05 The registered person shall make 13/02/06 arrangement for service users to receive where necessary, treatment, advice and other services from any health care professional – Previous timescale 04/07/05 A record of incidence of pressure 13/02/06 sores and of treatment provided to the service user – Previous timescale 04/07/05 The registered person shall make 13/02/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home – Previous timescale 04/07/06 To ensure, by means of fire drills 13/02/06 and practices at suitable intervals, that the persons working at the care home and, so far as practicable, service users, are aware of the procedure to be followed in case of fire – Previous timescale DS0000026113.V280729.R01.S.doc Version 5.1 Page 23 Requirement 3. OP8 17(1)a Sch3 3(n) 13(2) 4. OP9 5. OP38 23(4)(e) Shottendane Nursing Home 04/07/05 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. Refer to Standard OP18 Good Practice Recommendations It is recommended that staff undertake training in relation to the Protection of Vulnerable Adults. Shottendane Nursing Home DS0000026113.V280729.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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. 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